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tv   Today in Washington  CSPAN  September 4, 2009 2:00am-6:00am EDT

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financial recovery and how the global recession compares to the others since 1945. then max boot will take your phone calls about the report on the war in afghanistan. and we will discuss an upcoming supreme court case about campaign finance with adam liptak. this comes from a case called "hillary: the movie." "washington journal" is live every day on c-span. >> as congress comes back and gets ready to debate health care once again, we thought we would take this opportunity to look at some of the issues around hr- 3200, the house version of the health care reform bill. our guest joins us to help us put context to the bill, and we
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will show you some of the debate that happened earlier this summer. martin von, when you look at hr- 3200, how radical is it with regard to how much change it would bring to the current health-care system? >> is a pretty far reaching system. people know this is not just in criminal nips and tucks around the edges. this is an ambitious plan. the goal is to cover all americans and provide universal health insurance, and that requires radical changes in terms of the insurance market and the revenues needed to meet that goal. that goal. >> what are some of the me ant changes to the health care system as we know it now? >> one significant change is the one we heard about in terms of the democrats talking about a
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public plan to compete with private insurers. the market now is dominated by private insurers. the u.s. is not completely alone, but it is an anomaly internationally and among western nations in that sense. the effort is to create a government-run plan to compete with private insurers. that may be one of the more far reaching aspects of this. >> when you look at the entirety of the congress, or the house, 40035 members, -- 435 members, how are they reacting to it? >> a lot of nervousness, not just among republicans but certainly in the democratic caucus itself. both in the house and senate, more moderate democrats are
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nervous about the plan. they are hearing from their constituents back home. not all of them are on board with the idea of a public auction. the white house is attuned to that and is sensitive to that. we are hearing that the white house, when they say things like public option, we would like it, but it is not absolutely necessary. they are attuned to the voter nervousness about that idea. it is a hard sell, particularly for the moderate democrats. >> what about the progressive democrats? >> it is sort of an issue where you push the bill in one direction and one group screams, and you push it back in the other direction, and you have someone else screaming. it is like any piece of major legislation when it is offered like that. i think what we will see over the next several weeks is that as democratic leaders in the
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senate and house moved toward the senate -- toward the center to appease these moderate constituencies, we will hear a lot of yelling and screaming. i did not mean to be derogatory by saying that, but we will hear a lot of complaints from factions who are announcing their view of universal health care -- they are now seeing it watered-down. the republicans have offered their own versions of health reform, not as ambitious or with the same types of goals that the democrats have a completely remaking the system, but they have offered plans. one thing that is missing from the democratic plan that would be an essential element of the republican plan is the whole issue of medical malpractice reform.
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republicans are keen to point that out. >> we have touched quite a bit in this initial conversation on the public option part of the plan. we want to show you some ways and means committee hearings from earlier this summer that deal with the public auction. -- the public option. >> it says no government run plan. i enjoyed the questioning, and i wish they were still here. let me explain why it is a stacked deck. let me explain why the public plan is really a case where they are the player and referee in the same game. let me explain why it is really virtually impossible for a public plan to compete fairly on a level playing field with the private insurance market.
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four the damage is the public plan has. the public plan does not have to pay taxes. the public plan does not to hat -- does not have to have large capital reserves. the public plan does not have to account for its payroll and benefit costs of its employees. the private sector does. the public plan gets to dec take the prices it will pay for services -- speaks to dictate -- gets to dictate the prices it will play for services. let me tell you what a couple of actuarial firms who are reputed, often cited by both sides of the aisle, and who do it for a living. one group tells us in three years 122 million people will be pushed up their private health insurance. two out of every three americans will lose what they have and get pushed on to the public plan because of all these factors, because of the cost shifting that occurs.
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cbo does not think cost shifting is that big of a deal. if we are underpaying hospitals by 30% with medicare, where will they make up that difference? studies show that a combined family of four will have higher premiums of $3,628 right now because of medicare and medicaid underpayments. so we will at exacerbate that underpayment. let me read a quick line from an editorial today. "the public option will not be an option for many, but rather a mandate for buying government care. a free people should be i reached at this advance of tierney." pretty harsh words. these are words that i think are appropriate for this moment. what do we not say let's make private health insurance work?
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why do we not work together to make it affordable for everybody? what we not pass legislation to address the problems we have? people that do not have health insurance, people that have pre- existing conditions to cannot get it, and the fact that it costs are rising so much. we could do that together if our agenda was not to have a government takeover of health care. with the public plan, no matter what direction you look at, the destination of this bill is to have the public plan crowd out the private sector. i am looking forward to a vibrant debate on this point, but i urge my colleagues to think twice about this moment. think twice about the moment when you are going to vote for this bill, and think about what your constituents are going to say to you in three or four years when they have lost the health insurance that they have. 80% of americans like what they
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have got already. let's address those americans who do not like what they've got, and not take these things away from those who like what they have. i yield. >> mr. chairman, i would oppose the amendment, and like to correct the points that my friend from wisconsin brought up. admittedly, the public plan would be tax-free, but there would be many tax -- many private plans that are not for profit, so they would not be the only tax-free. as far as capital reserves, they would be built into the premiums charged by the public plan, and will establish whatever reserves are required by the various insurance commissioners. s to payroll and benefits, they will be fully paid for by the premiums paid into the public plan, and there will not be any government subsidize station to the plan. there will be perhaps to some
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participants, but they could get the same the subsidization for going into private plans. s to dictating prices, in so far as i am aware -- as to dictating prices, plans to have limited panels dictate or negotiate prices. the public plan will be no difference, except that it will create a new choice. many areas of our country dominated by one or two private insurers today. it will operate on a level playing field. it will be subject to all the market reforms and consumer protections as the private plans. it will be self sustaining, and there is one other thing that has been a driver for innovative delivery reforms.
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providers or counsel for productivity, payment in since for efficient areas, improved position quality of reporting. i could go down the list. eliminate cost sharing for preventive services. these are the results of a creative, flexible, quit moving plan which -- quick moving plan which should give the public plan the emphasis that will be followed by the private plans to make good changes for the delivery of medical services. so i would urge my colleagues to vote against the amendment and allow a plan to create the kind of competition that does not now exist in the private market, so that all americans will have the
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right to participate in a plan of their choice, but that there will be a choice there that will drive innovation, creativity, perform, and cost savings. >> mr. chairman, i strongly support the amendment offered by my good friend mr. ryan. this amendment goes to the heart of what we believe is one of the most serious problems with the bill before us, the so- called public option, which is really a new government-run plan that will threaten the health coverage of more than 100 million americans and put our country on the path to a government single payer system. i recognize that this is a controversial statement. many supporters of government run plans insist they are not really trying to have a
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government takeover the entire system, but you do not have to take my word for it. jacob hacker it is a political scientist who is credited with developing the idea for the government run option. here is what he said about it in a speech last year. "someone once said to me, this is a trojan horse for single payer, and i said, well, it is not a trojan horse, right? is just right there. i am telling you, we are going to get there over time." common sense should tell us the same thing. the majority says that the government run plan will compete with private insurance companies. how do you compete with the federal government, when the government is also setting the rules for the competition? there will never be a level playing field. there are any number of ways for
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the government plan to get an unfair advantage. the bill before us says providers will not be mandated to participate, yet the government can make it very unpleasant for those who opt out. the bill says consumers will not be forced to enroll in the government plan, yet the commissioner of the exchange can also enroll them. that is without even talking about all of that hidden subsidies that come into play whenever the government is involved in private business. make no mistake about it. this government run plan will be the camel's nose under the tent and hospitals while government bureaucrats take the place of doctors in deciding what medical
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treatment patients will receive, and it will mean sacrificing much of the medical innovations in which america is so proud to lead the world. i urge my colleagues to reject this dangerous course and pass the amendment. >> mr. levin? >> yes. i am going to yield back because, you know, we have heard those scare words before. they have been echoed for decades about government, that government is the enemy, that it will take over, and this
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proposal simply will not do that. it is not a trojan horse for anything except to provide care for all americans and also to provide innovation. a major reason for a public option is to drive innovation, to drive a change in the way we deliver systems. innovation, but to drive in -- to drive a change in the way we deliver systems. you all say you want that, and yet when it comes to actually supporting something that will help bring about, you oppose it. you like to quote cbo when you like what it may say, but you will not quote them when they
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say something that says you are wrong. cbo's estimate says there will be about 9 million people in this plan. it will be a small percentage, less than 4% of the insured population at the time. that is what cbo has estimated carefully. so when you bring up this imagery to try to scare people, it simply will not work, and the public is already on to that tactic. if you ask the public did they want this kind of public option, they decisively say yes. there is such an urgent need for health-care reform in this country, and so much of a need for competition with the insurance carriers, i cannot
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believe anybody seriously says that the public option dick takes all the private insurance companies do not. that is simply not true, and as providers -- ask providers if insurance companies do not dictate what they were received. if they are polite, they will not laugh. you cannot scare us away from taking steps that will truly began to change this system and provide affordable health care for all americans. i urged defeat of this amendment. >> let's be clear with the legislation is trying to accomplish. we are trying to accomplish a true national purchasing pool of exchange with a menu of health plan options for people to choose from. whether we like it or not, a
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large number of people in this country would like the choice of a public option in this exchange. we have been trying to do our best under this legislation and make sure that if there is a public option that moves forward, that it competes on a level playing field. it has to be self sustaining. whoever would be running the public option cannot be the one in charge of running the national exchange. an area where my friend from wisconsin may have legitimate concern is whether it makes sense to pay the reimbursement under the public option with current medicare rates. this is especially tough in areas where there has been -- why would we like in a system? there's more work that has to be done in regard to the adequacy
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of pegging reimbursement to current medicare rates. before this is ready for prime time, it is an issue that will have to be addressed. as far as competition is concerned, let's not fool ourselves. one of the reasons people want a public option is because there has been tremendous consolidation with the delivery of health insurance in this country. into many areas, there is not true competition right now. people would likeçó that choice, but some may not want to choose a public need a plan in the exchange that is run by private insurance companies who have different motivations, different business plans, profit motives that drive a lot of the decisions. ultimately, this is all about consumer choice. there is that recognition in the country today that there are a lot of people who would like the choice of a public option at the end of the day, instead of having to be forced to choose a
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private plan as their only option in this exchange. >> i cannot believe mr. kind, that you can see charge that the organizations involved, that there can be anybody that can make it work. reform is needed in our healthcare system. some do not have access to quality, affordable health care. to many small businesses are deciding between hiring workers are paying health benefits. we need to find real solutions to these problems that hit every household and every business on main street across the country. however, i am convinced a government takeover of health care is not the solution our country wants, needs, or deserts. i have posted numerous health care listening sessions to hear what the constituents think.
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no matter what health care problems that are facing, or what health care crisis they are struggling with, i heard over and over again that they do not believe more government is the answer. the problem our current health care system has is that we do not spend enough money -- we do not spend it wisely. we do not need more government interference. look at that chart. that thing is a mess. there must be nine people who tell us what kind of health care you are going to have, so what is a public plan? nobody knows. i cannot think of one instance in recent memory where the federal government getting involved in a problem make things better. once bureaucrats get involved in a situation, everything always gets worse. mr. chairman, i would like to ask unanimous consent and -- to insert in the record the chart you are looking at that shows
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how much government bureaucracy is designed to make this thing work. >> mr. johnson, i want this in the record, too, but where did this chart come from? >> it comes from the joint economic committee. we hated it with a paintbrush that you can recognize. the colors are red, white, and blue. that is american, isn't it? >> there is a lot of yellow in here, but i will leave that alone. this is a very attractive chart. the artist should be commended for it. mr. pomeroy is recognized. >> let me just say i support my companion's amendment here. >> you made that clear. >> mr. kind covered what i
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wanted to discuss, essentially. i want to oppose this amendment, even though i have very serious problems with the public plan as contained in the bill. the reason i do is because it does not paid fairly. pays on medicare rates, and there are portions of the country that are underpaid by medicare presently. you do not move forward constructive plea by building on a flawed foundation -- constructively. that needs to be changed. i am completely confident that this bill is not going to be the bill that ultimately goes to the president at the end of the enactment process. it is inconceivable to think that we would ultimately pass health reform rely on medicare rates for the public plan option. that is not to say that the public plan option does not have a role if this constructed to compete fairly and
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effectively. to suggest that the american people are locked into the existing health and st. -- existing structure that we have would be completely at odds with the constituents i represent. they think insurance shortchanges them at every turn, and more of a competitive presence would be a good thing. whatever ends up in the final legislation needs to play fairly, and it cannot be based on insufficient medicare rates. this leaves us with the same old health-care insurance coverage we now know so well, and that is why i say we should defeat it. >> mr. davis from kentucky is recognized. >> mr. ryan amendment to strike the government run plan from the underlying bill -- a government-
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run plan is simply unworkable. it does not get to the root problem of affordability or costs. it is called america's affordable health choices act. i do not know who came up with the name, but well over one trillion dollars is not considered affordable in kentucky. tens of millions of people -- he in my district, if you cannot find a provider who will see, it is worthless. the reason this bill must -- does nothing to address the core issue that some of us have been talking about for years. i not fixing the process at the core, we are going to increase costs, limit reimbursements, and reduce them. you cannot end up with anything but a rationed care system. reform and reengineered medicare and medicare services which are not in this bill.
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second, true reform of the private insurance system to allow competitiveness and increase access for small business and individuals, and the thing that has not been addressed here is meaningful, medical liability reform which is necessary to free our provider so they can function and do their job. one doctor in my district said who is going to sue me now? is the government going to sue me? without all three of the things i mentioned, we fail in our shared goal. this is not about politics and partisanship. it is about human lives. we are talking about spending well over a trillion dollars to get the bill and the public plan started, and we do not know what we are going to get in the long term. we do not have the details or the facts in front of us today because the process is being hurried along by artificially imposed timetables by people who
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have never worked in a professional health care world in their lives. this legislation will have generational impact. we have to take the time to consider the bill. we need to slow it down and get these practitioners from the field in here. i want to close with a quotation from an e-mail i received. we absolutely cannot reform health care in this country if we do not get a better grasp of what drives the health care costs. i am so frustrated because too many of the decision makers have little real knowledge of what needs to be addressed. is not as simple as cutting payments to hospitals or doctors. who will peel away the layers that find so much of the cost of operating a hospital? things like hidden energy costs, malpractice costs, that create defensive medicine, and on and
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on. i fear for the medicare patient, as more and more doctors speak of closing their practice. other than more, in my lifetime, i do not believe there has been such an important task at hand. it is imperative that the voices of many are heard. a government-run plan will not live up to the promises made by its proponents. it will reverse -- reduce quality at a gargantuan cost. >> thank you, mr. chairman, and i share your enthusiasm for putting the chart in the official record, the charge, by the way, that was not from the joint economic committee. it is joint economic committee republican staff, -- for putting the charts in the official record, the charge, by the way, that was not from the joint
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economic committee -- the chart in the official record, the chart, by the way, that was not from the joint economic committee. if we had some of the exports of our choosing, in one week, we could not come up with a chart that would reflect the byzantine non-system that faces american consumers today, a hodgepodge of costs, confusion, gaps, and inequality. what we have done here is, i think, make an initial, critical first step to try to provide choices to people who do not have meaningful choice. i do not think this bill is done by any stretch of the imagination. i do not think any of us do. it is, i think, an important step moving forward, but to pretend that somehow putting a
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lot of boxes and colors on a piece of paper is somehow significant and a confusing and some not determinative as to whether or not we should have a public option, particularly for the one half of american states that have no meaningful insurance competition, where one company has 50% or more of the any has speedy% or more of the market, is laughable -- has 50% or more of the market. i am pleased that the staff walked through the elements, and i hope that everybody does go ahead and correlate in pieces that are in there, because it gives you a sense of what is going to have to happen to achieve much of what there is a consensus amongst people on the committee on both sides of the aisle. i think the bill we have before us is a start in that direction, but it would be unfortunately
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handicapped if we were to adopt this amendment. i strongly urge its rejection. >> i support the ryan amendment to strike the government from the plan. i am intrigued by all the conversations we have heard about choices and options for the american people. the american people do not make these choices, their employer does. that me tell you what some of the employers are going to do. this government run plan was priced at 8% of your payroll. if you are not providing coverage for employees, you pay 8% of your payroll. the typical small business pays 11% to 14% per payroll. between two companies, they employ about 500,000 people. i ask the ceo's what percentage of the payroll went to health care costs. they both said between 15% and
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16%. i said if you could pay the government 8% and they would pick up, we do in your program and turn it over to the government program? they said in a heartbeat. this is designed to drive business owners, employers come into making economic decisions for their shareholders that wind up with employees in the government run plan. it will succeed. thank you, mr. chairman. >> why would the government possibly have a conspiracy to remove the obligation of employers to insure their employees? why would they want to do this in a heartbeat? >> is the same question i keep asking, and i do not have an answer for, but the assumption is this. most of the people writing these bills want a single payer plan. this is the way to get it. >> ok, ok.
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the chair is ready to take a vote. mr. davis is recognized. >> let me be brief. let me also say that i oppose this amendment strongly. as a matter of fact, the most important part of the legislation we arkin considering -- i want to protect all of the -- we are considering. i want to bring in those individuals who are currently out. i do not think we can have the balance we need unless we do have a public option, so i am opposed to the ryan amendment. i yield back the balance of my time. >> i support the ryan amendment, for reasons i outlined in my
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question. i think the government option is poorly conceived and is a recipe for financial disaster. with that, i will yield the remainder of my time to mr. ryan. >> let me make it clear that mr. ryan can take your time and his time. >> and try and address some of the things that have been said here. i wish my friend from wisconsin were still here. he is concerned with concentration of health insurance options in america. does anybody believe that after this bill passes and becomes law, we will have more options, in addition to the public plan? we are federalizing the regulation of health insurance. let me make my case. [laughter] we are adding new costly mandates, making health
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insurance more expensive. do you think the 1300 insurers out there will be able to compete in this environment? employers will be looking at a situation where the insurance they have will become more and more expensive. one study says that right now with medicare and medicaid cost shifting, is $88.8 billion a year. another study says that if this passes, the cost shifting will increase private insurance for a family plan by an average of $3,628. employers will be faced with a situation where a more people go on the public plan. the public plan under pays providers, and they make it up by overcharging private payers. cbo does not think there is much cost shifting. everybody else to talk to does. just think about it. ask any doctor or hospital in
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your district, and they will tell you cost shifting occurs. employers will see their insurance going up and up at unpredictable rates. they make a choice. i can keep paying this high-cost insurance that the government tells me what i have to buy, or i can just pay and 8% payroll tax and down my employees in the same kind of help richards i have to buy them anyway. -- health insurance i have to buy them anyway. we did not have a tight labor market. we have 10% unemployment. what employer is not going to dump their employee on the public plan as soon as the price of their insurance exceeds 8% of payroll, where it already does? the problem is this, mr. chairman. it is impossible for the private sector to be able to compete
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fairly with the government, with all its muscle and all of its tools. at the end of that process, we will see a situation where people will have lost their choices. employers will not be offering insurance to their employees. they will be saying, i am paying the payroll tax, you are going on the public plan. the payroll tax will be 23%. we'll have a 23% payroll tax in this country. this is not a good idea. if you come from places like where i come from, medicare under pays hospitals and doctors substantially. who is going to want to continue offering the services? i would urge my colleagues, get rid of the public plan, and let's work at fixing the private
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health insurance market so that it works better. let's not take away all these insurance products the people currently enjoy. >> as we close this round, i have the deepest amount of respect for you, and it is abundantly clear what you are against. you are one of the few people that have a plan on the other side. i do hope that before we conclude this marked up, you might be able to share with us who you persuaded on your side that you have a better way. i do not care what legislation we have. it is so easy to take a shot saying this does not work, this has to happen in 2023. at my age, i am concerned that what is going to happen at the end of this week. it seems to me that somewhere between now and the conclusion of this legislation, the chair is open to any positive thoughts
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that collectively might come together so that we might talk about it. it is a long way between here and the president's desk. i would like to get a vote on this, so all in favor of the bryant amendment indicate by saying aye. all opposed say no. clearly the noes have it. the clerk will call the roll. >> that was the ways and means committee debate. it was a portion of it. at the end of that, the chairman says he is open to alternatives to the public option. what are the alternatives that may be under serious consideration? >> there is one alternative that has gotten a lot of discussion in the senate. that is to have non-profit co-
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ops that would be an alternative to private insurance, but would not involve a federally run plan. it is an idea that has gained a lot of currency among rural centers, in particular senator conrad of north dakota and senator grassley of iowa. it is not an idea that has followed support in the house, however. it is not really tested. there are not a lot of examples of a co-op that would work in this sort of context, and the proponents point to rural electric co-ops and that type of thing. the biggest objection is that we do not know how it would work. there are questions of whether it would attract enough people to really function as we wanted
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to. >> are there any other alternatives that chairman rangel might be open to? >> aside from the co-op plan, that is the main alternative that has been discussed. >> another one of the concerns that has been raised during the debate has been the doctor- patient relationship and how that would change. in your reading of hr-3200, what do you see it would be the major changes? >> this is an issue that is very controversial. to hear republicans describe the bill and to hear democrats describe the bill, you think you are talking about two completely different bills. much of the controversy stems from new bureaucracies that the bill is creating to investigate things like how do we innovate in madison, and how we bring more quality to treatment so that we ensure we are getting the best bang for the buck, so
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to speak, in terms of the treatments that are delivered. when you start talking about that, that is when republicans make the argument or get concerned that are these bureaucracies setting standards are putting forth mandates that will dictate to the doctor what kind of treatments they can prescribe and what they cannot? that is what they mean when they talk about interfering with the doctor-patient relationship. there are a number of provisions in the bill. there are new centers that are called for to study these things. for the democratic perspective, they are looking to control costs. that is what these new organizations are for, to investigate how we can deliver treatment for less cost. when your in the minority, you have the luxury to point out
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things that are wrong and they could interfere with the doctor- patient relationship. a legitimately raise a question about that. >> is this where the death panels phrase comes into play? >> right, that is the catch phrase we have heard in the national media, based on a provision in the house bill on end of life counseling and what points folks in hospice care might get counseling about planning for that stage in their life. sarah palin used the term. some of the republicans that have used it sort of later backed off and said so that one got caught up in a little bit of hyperbole, but, you know, i think it really showed the sensitivity in the
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electorate, how strongly people feel about being able to choose their doctor, trusting their doctor's advice, and not wanting the government to interfere in that, so it is certainly a legitimate concern. >> another term that has been used is comparative effectiveness. what is that? >> that looks at dealing with different treatments at treatment outcomes -- and treatment outcomes and whether one treatment consistently has a better outcome than a different treatment. it is an area that the most would agree needs more research. and that is one of the things this house bill is doing, is providing funding and providing new avenues for that kind of research to happen so that information would be available
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to doctors and to the insurance companies to say, you know, "that treatment is really not effected." to -- effective." the idea is that you could get cost savings that way. >> the energy and commerce committee headed debate about federal employees and whether or not they should be in the middle of a doctor-patient relationship. here is part of that debate. this is about an hour in 20 minutes. >> the clerk will report the without objection, that amendment will be considered as read. >> this amendment would prevent any federal employee or political appointee to dictate
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how a medical provider practices medicine as a result of the development of best practices by that center for quality improvement. mr. chairman, doctors and their patiencts are really sacrosanct, and the doctor-patient relationship is extremely important. the center for quality improvement is similar to the nice organization in the u.k. system, the national institute for health and clinical excellence that makes decisions under their system that basically denies certain coverage. i would reference particularly in cancer therapy, chemotherapy, wherein the results that the
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five-year survivability of prostate cancer and breast cancer is significantly less than it is in the united states under our current system. mr. chairman, that is simply because this so-called oversight group makes decisions based on costs, and not necessarily clinical effectiveness. i have no objection to the center for quality improvement to do research, hopefully scientific research, to come up with what appears to be best practices for each and every disease. but they have to take into consideration the fact that patients very, and who knows that better than the doctor that maybe has been treating the patient for 25 years, who
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specializes in a particular disease, whether it is diabetes cancer, and knows that this patient is on medications that might conflict with a certain treatment that happens to be found to be the best practice by the center for quality improvement, or the least costly, but yet the doctor knows this patient should not take that drug, and that there is a better drug for him or her? when we heard last week on monday, the director of the congressional budget office talked about the fact that in looking at this bill and the bill that was passed by the health committee in the senate,
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there is a bending of the growth curve in regard to the cost of health care, but is bending in the wrong direction. my fear, and the purpose of this amendment, is that when we signed up 97% of the people in this country for health insurance, universal coverage, we are not going to be able to meet those obligations. it will be like noah's ark, and you put too many people on the ark, and it may take a couple of years, but it begins to sink. so you decide you have to get rid of some of that baggage, and you began to throw people overboard. who gets thrown overboard first? it is the sickest, those suffering from illness.
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i think it is very important that we do not let that happen. doctors are smart enough to understand that the center for quality improvement says what works best -- they are going to take that into consideration, but they cannot be forced, or should not be forced to practice under the dictates of some federal employees for political appointee who really has no medical background. they may be good it business -- good at business, or maybe even a former governor, but they do not practice medicine. mr. chairman, i would hope that everybody would agree with me that this amendment needs to protect these patients so that doctors can continue to practice medicine as they see best,
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taking into consideration the recommendations of best practices, but not be dictated in regard to how the country. >> the gentleman yield back his time. >> i would like to speak against this amendment, and here is why. this amendment says that this would not allow any ago federal employee our political appointee" at the center for quality to dictate how any doctor practices medicine. this is very broad language. this is an innovation that both
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sides of the aisle have nailed as a major advance in care. when doctors follow a simple checklist when doing certain procedures, a certain type of health care associated infections can be nearly eliminated, saving tens of thousands of lives and millions of dollars if implemented nationwide. if the center were to try to assist in the implementation of the check list, this could easily be construed as " dictating the practice of medicine" but the check list is exactly the prototype of what we wanted to develop. this language could prevent them from carrying out its essential task, to develop new and innovative best practices to improve the quality of health care in the united states. scientific dances, if done properly, should change the practice of medicine -- scientific advances. we would never pass a law that said to the national institutes of health that if they develop a
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new therapy, doctors should not use it or could not use it. that is exactly what this amendment says. i urge my colleagues to vote against this. >> just to add to the broadness of this amendment, i would agree that we want to really think -- we do not want to deal with how doctors practice specific madison with their patients, but this is so broad, -- how doctors practice medicine with their patients. this could go to the overuse of tests are too many of the provisions we are trying to get at with this bill to improve the quality of medical practice, while at the same time making it more cost-effective. while it looks appealing on the face, i think this is going to undermine whole legislation.
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i urge a no vote, and i yield back. >> i rise in support of the amendment. it is simple. nothing in this section shall be construed to allow any federal it bought -- appointee to dictate how a medical provider practices medicine. it does not say bills for medicine, researchers, it says practices medicine. if the majority is right the congress women really do not want to prescribe help doctors practice medicine, we ought to accept it. all he is attempting to do is make sure that these new components in the legislation do not end up actually giving
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bureaucrats the power to tell doctors how to practice medicine. if that is not the intent of the authors of the legislation, this ought to be accepted by unanimous consent. we are going to make this point over and over and over and over and over again in this markup. most of us on the minority side believe in the marketplace. we believe in transparency. we believe in choice. we believe in letting diversity -- we are not opposed, if you want to put out a check list for best practices. the next amendment we are going to offer is one by me on transparency. you want to put out results of surgery's, and if you want to put transparency into pricing, we are all for that. if you want to compile best practices and innovative research and make that available, you want to do
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internet technology, we are all for that. what we are not for, and you create so many new bureaucracies, so many new positions of potential authority and mandate in washington, where people that are not trained doctors have the ability to dictate to the medical community how to practice medicine. it is not technical language. simply, we do not want the bureaucracy created under this provision, or the presidential appointees of either party, if this bill becomes law, having any hint of the ability to compel our medical professionals how to practice medicine.
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>> what he is saying is exactly my intent. the argument about not following best practices as determined by the center for quality improvement, or whatever the committee is called an whatever country, i am not opposed. i think doctors should pay attention. they should fall best practices. if it is a five step process of protocol, or 812 step protocol, i think that most physicians would follow that suggested protocol. let's say a situation where a neurologist has found that in the last three cases where he has suspected that a patient may have a malignant brain tumor, that he ordered a cat scan, and
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the report was negative, there was no evidence of a brain tumor, but his clinical acumen, his gut feeling, if you will, told him that there was something wrong with this patient. so he felt like a more expensive test, an mri, should be done, and these cancers were detected and these patients had an opportunity at a very early stage to get the appropriate chemotherapy. not just to improve their five- year survivability, but hopefully to cure them. i think a doctor in that situation would be willing, if the center for quality improvement wanted to slap him are on the wrist and say we are not going to reimburse you as much, they would gladly be an much, they would gladly be an acceptance of that
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and i yield back. >> i support the amendment, and i yield back. >> the gentleman's time has expired. >> thank you, mr. chairman. i does want to express, because of what the previous speaker said, when their innovations or practices this suggests or develops, i am not going to to a reimbursement rate or m&a on physicians. -- mandate on physicians. the problem is with this amendment, you kind of throw water on innovation. you suggest that somehow they should not develop these practices because they may somehow hinder a physician from practicing medicine, and that is not the case. there is nothing that they would develop that would be mandatory or would say that a doctor would not be reimbursed if he did not the only thing it would do in my
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concern is that it is going to hinder the development of these practices. there will be -- it will interfere the practice of medicine. there is nothing in here that the mandate -- that is a mandate. i know there suggestion of that on the other side. >> i do not think any of us in opposing the amendment are suggesting that we think doctors should be told how to practice. i think the concern is, and it is ironic because the name of this construction, we are concerned that this provision could get country in a way that would end of discouraging the kind of best practices and implementation, which you agree ought to happen anyway. i think the language of this and the potential for it to get construed such that you then
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create barriers to the encouragement of best practices, which is what we are trying to do. that is the problem. it is not that we want to stand in the way what the physician want to do. we are worried this could end up working against best practices. >> i with trauma point of order. -- i withdraw my point of order. >> and a lot of these -- i want to read this from the july 7 wall street journal. the british officials who is -- established a rigid position as a body that would insure the government-run national health system use best practices in medicine. as the guardian reported in 1998, health ministers are setting up nice designed to insure every treatment operation for medicine years is in the
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proven best. it will root out underperforming doctors and useless treatments. that is exactly what i hear my colleague on the other side say. what has it become? nice has become in practice a rationing board. as health care costs have exploded, even in this bill, the cbo has predicted that it will float -- in britain, it has become the heavy debt reduces spending by limiting the treatment that 61 million citizens are allowed to receive three the nhs. march comedy ruled against the use of two drugs that prolonged the lives of those with certain forms of breast and some cancers. after last year's ruling, director noted that there is a limited pot of money that the drugs were a marginal of benefit
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and quite often an extreme cost and the money might be spent elsewhere. the board restricted access to the two drugs for regeneration and blindness. if they allowed this drug -- he was going blind into eyes -- they said, we will pay for the drug in one eye, but you can go without the other eye. nice limited the use of alzheimer's drugs. it includes the rejection of a drug for rheumatoid arthritis. it is a subject of protest. they even have a mass formula for doing so based on quality adjusted life year. i am telling you, folks, if we move this direction to socialize medicine and the best intentions of the best practices, we are going to end up with a rash and
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health care system where people who need care will have to try to find some other country to go to. guess what? they are not out there. if you want to set up this quality board and you want them to subvert doctors and the doctor/patient riel -- relationship -- as they did in england -- go ahead. we are not want to be any part of it. >> 5 thank the gentleman for yielding. this is really straightforward. it is very fundamental. read the words of the amendment by dr. degree. -- dr. gingrey. says they may not dictate how a medical provider practices medicine. if you oppose that, then you decided that a federal bureaucrat should be able to and can dictate how a medical provider practices medicine. if you are going to do that, then you are going to assume
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medical liability for every decision that she meant it. this has nothing to do with suggesting best practices. this has nothing to do with informing doctors of what is the least expensive form of care or effective if a doctor were advised that the best practice was to do what was suggested and did not do it, that would be malpractice. they could seek a remedy for that. this is not a question of it innovation. innovation can from doctors as low as government boards. the question is, do you want to put the doctor between -- put in the federal government between a patient and his or her doctor? i would suggest to you that the practice of medicine is in part science. we can make suggestions to doctors as to what the shooter should not do.
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-- should or should not do. if you think we should have federal employees telling doctors how to practice medicine, and then we are abandoning medicine as it is taught in america's medical school in this country. i think the ama better listen. you are embracing that a bureaucrat is going to tell your doctor how to practice medicine. if that happens, we are giving up all form. look up the word "dictate of " it says "mandate." >> the gentleman's time has expired. who seeks recognition? >> having worked on health care both in insurance and legislature for a number of
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years and the committee, the amendment is so simple that it almost seems so easy. it is probably the ultimate gotch-you amendment. i listened to the side the we have the night the kingdom with socialized medicine making decision. this is not a socialized medicine bill. it is not, no matter how much to say it is, it is not. we are taking advantage of the 60% of the folks to get their health insurance through their employer now. that is going to be continued. this is not a single payer like the uk. you brought of medical malpractice. if we do not pass this, the federal government could be the person who ultimately get sued. we are not a practicing medicine in this bill. nothing in this bill dictate medical practice any more so than --since 1965, medicare has not all doctors how to practice.
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i beg you this amendment would probably could have been germain in 1965. we can go back and say in medicare action to tell somebody that they tell you what you are being reimbursed for. blue cross says that with my interest. blue cross does with my insurance. it did well as a state employee and manager of a printing business. if that is what is happening now. this bill does not allow any federal employee to do that. i would say that if you make an argument against this legislation, maybe you should have made it against medicare, which is probably the second most popular domestic issue in our country only compared to social security. this is not a national healthcare like the united kingdom. it has so many variations of it. i get as close as you could get would be the netherlands to have a national healthcare and backed away from it.
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they have employer responsibility and individual responsibility. that is what is in this bill. this is such a simple amendment. it has no bearing on this bill, because it has been the to do the federal employee telling a doctor how to practice medicine. that is why the amendment should be voted down. we really do not have a federal employee provision in here or political appointee that can tell someone or a doctor how to practice medicine. i yield back my time. >> for the debate on the gringey amendment. >> this get to the heart of the debate. i take the gentlemen at his sincerity. if you read this bill, it is a bold face life. it is disingenuous to tell the people if you want to keep your health insurance that you have and they will be able to keep a. there are perverse incentives in this bill.
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that is if your employer keeps a. ask your employers if you can pay and a% payroll tax or pay 15% per employee for health care. what decision will you make? they will make -- a study shows 114 million people will be shoved off with their private land and on to the government plan. employers to not want this hassle to begin with. you set up a perverse incentive not to offer health care to their employees. that is dangerous. the one thing -- way the government controls cost in health care is by rationing care. -- and/or reimbursing at dave rate less than cost. welcome to medicare and medicaid. now you have 100 million people shoved into a planet does not reimburse at the right rate and you have a huge problem. we make up that difference by the number of people in private
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insurance. we are shoving 100 million people of private insurance. where does the money come from? this notion that you can tell people and say, you will get to keep it if you wanted only if your employee offers it. there is every incentive -- do not take my word for it. talk to your employers. they cannot wait for this to happen. there one to show other people off of their private insurance. -- they are going to shove people off of their private insurance. i would not ask my mother or my daughter to go into a system that i know would not allow them to survive breast cancer at the same rate that we have the ability today. that happens. i will tell you why. let me give you an example. a 19 year old persons the doctor blood in the urine. a healthy 19 year-old playing football. they come to the conclusion that person has been charged and take
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a few days off. thank become a doctor said, i have watched this patient for 15 years. something is not right. something does not seem right. i want to do further tests. everyone says, do not do it. it is crazy. frankly, that woman doctor wins and the patient find out they have bladder cancer. the statistics of that for almost impossible. had that dr. not been able to act on her hind and her medical science and history with that patient, the patient would have been dead at age 26. that patient was me. i take this very seriously. when you start talking about getting involved 20 doctor and patient and this bill will do it -- to not kid yourself -- it is the only way you can cut costs.
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they would have said specifically you cannot have that bladder cancer. that person should not have that treatment. that is exactly what they doing kennedy. it is what they do in great britain. if you look at the cancer statistics, and that is the general population -- in bladder cancer survivability is pretty close to 99% in the united states with treatment burda and the other two countries, it the combined is 75%. it is fitting for breast cancer in cervical cancer and skin cancer burda an. they made the trade gap. we will expect that some are young women will die of breast cancer. we will accept that. that is the trade-off they made the. if we say we will not even draw the line in the stand, we will
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not allow a bureaucrat or a politician to get in the middle between the doctor and patient so they can survive. @@@@@ @ @ @ h
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amendment that lets people and practitioners continue to make the final decision. >> thank you. i would like to direct some questions to the staff about this. there are a couple of interesting words here that concern me. first, nothing in this section shall be construed. let's take the word is section. what does the word section cover? >> it refers to section 931 of the public health service act. >> it covers the whole act? >> no, certification. it is 931 of its.
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>> what does that do? >> no center for quality improvement. >> then it says shall allow any federal employee or political appointee -- who would those be? that would be anybody. it to the food and drug inspectors. it could be the secretary of hhs. it could be the director of the social security program. it could be cms. who else could it be? what's mr. dingell, the provision would be broadly construed as any federal employee. that could include the commissioner of food and drugs or the director of the senators for the center of disease control. >> anybody in the federal government dealing then with
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federal law would not be able to do anything that would be construed to dictate how a medical provider practices medicine. is that right? y? es, ir. -- is that right? >> yes, sir. >> it could be a doctor commoners? >> yes. >> it could be a doctor on the floor in the hospital who is going to decide when a person will get a particular shot? would this rebate to the handling -- relate to handling of controlled substances? >> to the extent that it is otherwise covered in this section. >> could relate to food and drugs? you are saying you cannot give this particular drug because it
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is unsafe or it is out cited the approval that has been given by the food and drug? >> to the extent that is otherwise covered in this section. yes, sir. >> can include a wide array of other people including nursing homes? >> yes, sir. >> hospitals? >> yes. >> could include laboratories? >> yes. >> could include anything in relation to billing practices? >> i am sorry. i do not know. it is about a medical provider practicing medicine. >> could it relate to who is
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qualified to it ministry predicted ministry -- -- could relate to is qualified to administer this? could it be the anesthesiologists? could this relate to the making of decision in that matter? >> to the extent that it is otherwise covered by this section. yes, sir. >> what is the position? it virtually says that the administrator, the head of cms, cannot address questions like what kind of activities are permitted to be practiced.
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whether an individual is going to get a shot at a particular time or not. whether or not steps are taken with regard to that seen a kid it -- seeing that a patient does not get bedsores because he or she is not routine enough. >> @ -- to the extent it is otherwise provided. >> it might also prevent food and drugs from saying that a particular 1c pharmaceutical cannot be used or has to be recalled? >> to the extent that it is otherwise provided for in this section. yes, sir. >> i think we have a dangerous amendment here. it probably needs some redrafting. i yield back the balance of my time. >> thank you. i do support the gingrey
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amendment. over the years, whether i was a state senator in tennessee, be it had to deal with the funding of the funding. we have always looked it these issues. i said, how do we preserve access to affordable health care for tennesseans? i think that is at the crux of what we are dealing with as a look at this legislation some of us are very concerned that we have a bill that is going to put the bureaucrat in the exam room between the patient and the doctor. we have had so many people go through this -- the professions and not the rich and legislation. -- and not be written and legislation. the patient is left out of this equation. when we hear some of our
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colleagues talk about how this is going to be paid for, how is it going to be funded -- well, we are going to raise taxes and the wealthy are going to have to pay and small businesses will pay and seniors and medicare savings. that is going to be used to help offset the increased costs of this national health plan. those seniors a fear rationing. they are talking about it a lot. i am grateful they are talking about their fears. there are afraid of losing access. so are parents of children that have chronic diseases that need ongoing care. they are very concerned about the restriction and the caps that are going to be placed on care, that are going to deny those children access to those processes.
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i am very grateful that he has brought this amendment forward to say that you cannot do that. you cannot let a bureaucrat practice medicine and make those decisions. they cannot interfere with the practice of medicine. i am very pleased with this amendment. the amendment deals with such a 931 -- section 931. that section that deals with the center for quality improvement. i think that is important for us to realize. you cannot have a bureaucrat making those decisions. i am appreciative of the amendment. hopefully, it will move to something that is patient centered than something that is going to be more power to the government. with that i yield the balance of my time for mr. gingrey.
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>> i thank you for yielding. i want to address some of the questions that was as of counsel. we certainly appreciate the depth of his experience. those questions needed to be asked. as she points out, this is a very low -- very narrowly drawn amendment. it is applicable to section 931. let me repeat it. this amendment would prevent any federal employee or appointee to dictate how a medical provider practices medicine as a result of the development of best practices by the center for quality improvement. the bureaucrat could not use of best practices to dictate what a doctor could do. with that, i yield back. >> i yield back my time.
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>> mr. doyle? >> thank you. it is always amusing when you hear this argument that we do not want to let bureaucrats make these decisions for patients. like the current system is somehow letting patients making a decision. i love to see a poll of americans and ask them whether they like to see someone in washington with no profit motive make a decision on what it paid for purses a bean counter at an insurance company. that is what we are comparing. they say parents ^ -- our word of the caps. but as counsel -- i want to ask counsel, what does the bill say about caps on coverage? >> i believe that other portions
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of the bill, not division "c" do not allow for annual caps. >> does it not been lifetime caps -- the answer is that it banned them. does it not? the very thing that my friends are worried about is taking care of in this bill. heard someone here say that people are going to be forced into this plan. companies can just dump their employees. it'll be probably ellis' eight years before that can happen. it is up to the secretary of hhs to make that decision. once these decisions are made in the health exchange, there is going to be a whole list of private companies as well as one quality public plan. no one is going to be forced into this public plan. if people want -- the make the
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decision. once the employer says we are going into the exchange, they make the decision on plan they pick. they can pick anyone of any dozen private plans and same private insurance. no one forces them into the public insurance. but at least get the terms of this debate street. no one is being forced into anything. >> would the gentleman yield? >> i appreciate your yielding. i want to point out that the american medical association sent a letter in support of this legislation. it is hard --the american medical association. they support this legislation,
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because it is key to an effective reform. >> i will be glad to yield to my colleague from the virgin islands. >> thank you as a family physician, i am and averse to being dictated to as to how to practice medicine. i have read this section 931 over and over. i see nothing in their that suggests that anyone in the federal government would have any authority to dictate to a provider how to practice medicine. there is certainly nothing in there that would even suggest that there would be any support for any kind of rationing of care. in the implementation, it sounds involuntary arrangement withand some incentivizing of those
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entities that are entered into the agreement. i oppose the amendment. i think that a lot@@@@@@@ rr insurance companies has to wonder code which reject the policy because it may cause them to much money.
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-- them too much money. they say $300 million by rejecting an depose market review. when you get sick or have blood in your during -- when you get sick or have lead in the your urine, and they rejected. we need to stop the practice of rescinding policies what people get sick. they told us we will continue. we will continue. the only way to solve it is to have national health insurance. we should reject this amendment and move on with this debate on more meaningful things. >> who seeks recognition? the gentlemen. >> thank you. i want to make a point about
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the report, independent and non- partisan. its in the [unintelligible] c-span.i was a small business or for 22 years. i understand the cost of health insurance and providing i have evaluated the penalty here on small employers. i cannot run a calculation where it makes financial sense for a small employer to continue to provide health care the way this is crafted. if your payroll is $300,000 a year, your penalty is 2% if i'm reading this right. health-insurance costs are probably 12%. i have been trying to figure out all weekend -- this is a perverse incentive that will encourage those who are providing health insurance today to stop providing it is
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because it is multiple times cheaper to pay the penalty than to continue to provide and operate under this government's mandate. i think we may not believe that will happen and that economics does not work in the real world, but i think they do. i think economic principles continue. employers will make tough choices, especially in a down economy. they are faced with a mandate or if they go along, it requires them to provide health insurance to the family and the employee and a 72.5% for the employee. if they are not doing family coverage now, that is a huge additional costs under this bill. it is even more of an incentive. you are destroying the healthcare opportunity that is out there today for people who have it. that is going to go away. everyone is going to be put in
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the exchange. i want to yield the gentleman from michigan. >> i wanted to clarify that the health care did pay for it them. it would not have fit the profile under what the government around here has to do a checklist of things that are approved as a best practice for comparative effectiveness. by statistics, it would not have met their threshold. that is the danger. i'm going to read all of the cancers -- and which read them all. double digit, less survivability rate than those countries because they make the choice of not covering certain things. they say they are willing to have people have a higher mortality rate when you get these cancers because they are going to provide government ran care. i'm going to read them. prostate, scan, breast, bladder,
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cervical, lymphoma, leukemia, overeat, melanoma, brain, stomach, long, and pancreas. they decided in those countries they are willing to have more people die from these cancers in order to cover other people. what we are saying is the we are trying to cover 15% of the people. this amendment is to the heart of this bill. stay out of the patient/doctor relationship. the only way have shown to do it in the civilized government run systems is by rationing care. and is the only way they can contain costs. when you take 100 million people, if they go off of their health care and are put on to this government's plan, guess what? they are going to have to ration care. how do they do that? with your best practices checklist and your comparative effectiveness checklist. that is how they do it.
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that is what this is proposing to do. that is why we have to set a clear tone of front that we will not put up with that in the night the state of america. but with the gentleman yield to me? >> a one-council some questions. and did i want to ask some questions. this is an amendment that relates to section 931. is there anything in section 931 that would take away the authority of the fda to regulate drugs or devices? >> is there anything under this that would change the regulatory scheme for dangerous drugs or schedule drugs? >> no, certification. >> is there anything in this section that deals with changing
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the scope of practices to what a nurse or doctor can do? >> under other existing statutes, and no. >> not under this one. >> if there are authorities under existing statutes, they would remain unchanged by this. >> this amendment the when not change to the law -- would not change a lot? >> the main of the current law on these topics. -- there may not be current law on these topics. this amendment would not change those other statues. >> thank you. >> the time has expired. >> on this issue of caps, if you read the bill, the lifetime limit on capps has been lifted. this is a very important
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provision in the bill. in 1996, i introduce legislation and called christopher reed who is still alive in asked if he would allow this -- his name to be placed on the bill. he was a very good example of someone who incurred something that was catastrophic. most people do not realize what is in their insurance policy. this is acutely felt in the disabled community. i think it is important to note that it has been cured in this bill. members have made reference to what the report said. it was written months before this provision became part of the underlying legislation i think it is important for members -- it is a refresher --
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the organization is owned by united healthcare. united healthcare was the one that came before the investigations in the oversight committee and said we are not changing our practices for recision. come on. let us get our facts straight and know that we have philosophical differences. they should be debated. we need to deal with the facts. when you are talking about caps, the caps are no longer going to be extensive. the american people are going to be 1000% a better off as a result. thank you. >> thank you. i gave some thought to debating the amendment here. since no one appeared to want to do that, maybe that will be out
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of character. this amendment, if i read it right, just deals with federal employees directing medical professionals. i heard someone say like that in the most americans would not like to detect aircraft that had a bad day the day before to make that decision and said their doctors. that is all this is about. there are other sections that deal with insurance companies. i think you'd find substantial interest in making the air insurance system more competitive, making it more responsive. competition has impact on price. the current system grew up to where you do not really have the kind of marketplace we could easily achieve. our concern is different than this concern. it is great. many of us believe that government cannot compete fairly. the loewen group has been around
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over four decades. it is always described as a left of center healthcare group. it is never been described as conservative or right of center. it is well respected. there have been two studies. the first one said 160 million people will leave their insurance. on this bill they said 114-125. it was pretty close to this bill. it is hard to score this bill when you do not see it. to have that they are not that no one has for this bill yet, they scored two years ago. everybody believes that if you have a public competitor that is at near medicare, that the private competitors will get smaller and they will eventually go out of existence. that is another debate. this is a debate about whether a
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federal power gra power can intt is about a federal bureaucrat and medical practitioners. we have all the debate on the other part of the bill we want to. that is not what dr. been reposal bill deals with. -- dr. gingrey's bill deals with. i support the amendment. >> i wheel to the chairmen. >> i want to reiterate what he just said. this is about practice of medicine. that is what it is about. i would use the word " innocuous." but as -- if i ask for a show of hands, how many people think somebody washington to tell your doctor how to practice medicine on the year? i do not think anyone would raise their hand.
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i would not raise my hand. i do not want my doctor to be told how to practice medicine on me or my family. that is all he is trying to do. >> will yield? -- will yield? >> the difference in the argument here is who is standing between patients and their doctors. >> we do not want anybody to. >> we believe undecided the ideal that insurers due time and time again. i have not met over the phone a really bubbly, pleasant, welcoming helpful bureaucrats from an insurance company. i have to tell you that. i dealt with a lot of them when i had my mother and father. this idea then there are bad guys in the government and good guys everywhere else, i think that is overly positive i
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appreciate you giving me time. >> i have had health problems. i have been in several hot examination rooms and even a few hospitals with various ailments. i have never had an insurance agent in the examination room or hospital room when the doctors were in near trying to discern what was wrong with me and what to do about it and implementing their strategy. if we want to have a debate about insurance companies, i have a feeling some of us on this side -- in fact i know, this is about doctors, patients, drand doctors practicing medicine. if you think doctors to practice the best medicine on you and your family, vote for dr.
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gingrey. he think they should not be allowed to come of vote against him. >> @@@@@ @ @ @ @ @ @ @ @ @ @ @ å> hmm b)yáh not for had it to the state. we all know there right now the practice of medicine is regulated and of 50 states.
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in your amendment, if you are trying to prohibit a practice that already is prohibited by the 10th mmm. is that not correct? >> i've thank him for the question. i guess the gentleman was for the first amendment that was offered by my colleague from georgia -- [unintelligible] he brought up that point. the fact that the state have the right. it is protected by the 10th amendment. we heard general counsel say that absolutely under this bill that the state could be pre- empted under this section by the center for quality improvement. it says all plans for state employees have to cover certain mandates, maybe including abortion coverage. i am glad you asked me the
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question. i'll be glad to answer any other ones. >> i think that the bottom line is that the purpose of the amendment is already protected under the constitution. nothing that we do in a federal statute can interview with the constitutionally protected rights of the state to control the practice of medicine. that is way the constitution applies to medicine right now. i also want to talk about this issue compared effectiveness research buand its impact on breast cancer patients. here is a situation why it is so important in 1981, a well-known doctor who is working as a doctor at kent institution developed their week involving high dose chemotherapy. he came here and probably presented a presentation to some of the members of this
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committee and he said that if they did not pass approval for this experimental and expensive treatment the seven a breast cancer patients in the audience, half of them would be dealt with in a year. he told members of congress as to look at a woman across the table from you, as yourself is the price of her life where the price of a luxury car? here is the rest of the story. he were to another physician named fred. he warned dr. peters against accepting high dose chemotherapy without independent validation. he was ostracized by his colleagues. dr. peters, the one who invented this treatment, became concerned enough that in 1991, and he convinced the national cancer institute to fund a clinical trial to make sure that his treatment was safe. five different clinical trials were presented in the summer of 1999 at the annual meeting.
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those five clinical trials found no advantages and out comes between conventional treatment and high dose chemotherapy with bone marrow transplant. what was the price? roughly 42,000 women, 30,000 in the 1990's alone were subjected to the risk of this entirely experimental treatment. 34 $4 billion was spent. they later determined that 9000 patients died not from their cancer but from the treatment that they hope to be their cure. that is why comparative effectiveness research is important. that is why it is important to make sure that we have in this bill in the unbiased language. >> we've had a lot of debate on this. >> who seeks recognition? >> i do. i would ask you to yield two others who are seeking
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recognition on your site. >> what do you telling me to do? >> you are recognized. you had your five minutes. >> we talked about the 10th amendment and of that. the [unintelligible] this amendment is so simple there is not a high school kid that cannot understand here are we have taught almost an hour and a half on it. it simply says nothing in this section shall be construed to allow any federal employee for a political appointee to dictate how medical providers practices medicine.
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you have read that. that is simple. is there anybody anywhere that does not understand that? you have to consider this act based on the most simple medical practice like delivering a baby. for the most severe medical practice, a coronary bypass. i just wonder who would be the most capable federal employee of health care? crawly the architects of the capital. -- probably the architect of the capital. he would be the greatest political appointee. i do not know if it is the guy that has control of the trade for all the other nations in the world. i do not think you want him telling your doctor. would you want any federal employee to tell a doctor [unintelligible] would you want the architects of
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the capital telling him how to deliver a baby? i do not think you will. would you want any political appointee -- any of these that obama has appointed -- any of them to tell the late dr. how a coronary bypass ought to be run? that is of certification. nothing in this section shall be construed to allow any federal employee or political appointee to dictate how medical providers -- is that simple. i do not know why we have all this problem with all this. of course insurance companies try not to pay losses.
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this is so simple that anybody in the world ought to could read this and vote aye. i yield back my time. >> a couple quick things. when i was a state senator in pennsylvania, i wrote the patient bill of rights. it deals with managed care. insurance companies were making a lot of decisions. there were people who did not practice medicine in taking over decisions. the government is going to get into the insurance business. if that which is not specifically forbidden is permitted. this specifically to forbid it otherwise it would be permitted. i hope my colleagues will be cognizant of it. the government was to get into the insurance business. we should make sure we do not repeat the mistakes that occurred before. >> thank you.
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>> if we are trying to figure out consequences of this, if we are going to have this that will set of best practices, will it be setting standards and thereby having an impact upon medical liability that uses community standards? >> the provision in this section is to identify best practices for their it does not have an ability to set enforceable standards for any practitioner. nor does it have the authority to set community standards for liability concerns. there are no enforcement provisions with in this section.
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it is to develop research to identify best practices. >> i think that is very helpful. none of us want anything to come between us -- a doctor and patient. that is what this is about. we do not want there to be a government board that is going to mandate the standards. you are telling me that is not in this long? >> then everybody should support the amendment. >> i'm not want to yell back to anybody else. i want to simply close with three reading this. nothing in this section shall be construed to allow any architect for any political appointment to secretary of treasury to dictate how a medical provider practices medicine. breed of then vote. -- read it then vote.
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>> i want to enter into the record that this report from the louisiana medical society opposes this legislation be entered into the record. they say "the most radical of the bill's provisions, the public plan option, is against louisiana state medical society policy which is an opposition to a national single payer system. it represented a way to a vast expansion of government control of the nation's health-care system and is a stalking horse of a thriving market place o." the biggest concern many of us have expressed every government- run plan is looking at the history the other countries that have it. it to the canada and england and you will have the experience, the first thing they have done is rationed health care for the people in their countries.
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>> you do not think we have rationing in this country? they are people that cannot access to any medical care because the insurance companies will not cover them. they have nowhere to go. >> you are reclaiming my time. you actually taxed those people that are uninsured. you impose $29 billion in new taxes on people who are currently uninsured. that is on page 167. we actually taxed people at $29 billion who are uninsured. i support the amendment because it shines a light on the fact that it will ration care. this bill interferes with the relationship between the doctor and patient. if anybody can show and look at this organizational chart is a government is not interfering but the doctor and patient, then
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you have not seen it. this is the patient and doctor. these are all the bureaucracy's better being set up ticket between the doctor and patient. it is in the bill. what dr. gingrey is doing is saying remove all these federal bureaucrats away from their relationship so that the doctors and the patient can choose what is best for the patient. instead of what canada or england does. we have seen what they do. i'll be happy to yield to my friend. >> i'm thank the gentleman from louisiana. i want to bring up a point in regard to his idea of louisiana medical society. i will tell you that my state of georgia feels the same way. they are leading a coalition of about 16 other states that are all part of the american medical association that do not support this bill because of the
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government option. as the chairman mentioned, the support of the ama. it is a great organization. it represents about one/for the physicians in the united states. i do not think that speaks to all of the practicing doctors. the me say this as we come to a conclusion of this debate. the arguments that i have heard in the last 35 minutes -- it is nothing but an attack on the insurance industry. we can agree with a lot of things in this legislation, certainly ending this practice of rescission. because those of the technical language on their application there deny coverage. we agree with that. we agree with most of the insurance industry reform that is in the bill.
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denial of coverage for pre- existing conditions, community ratings, we agree with the need for electronic medical record and transparency. @@@@@@b@ @ @ @ @ @ @ @ @ @ @ @ h
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>> will the jerk -- will the german yield to me for a question of mr. kingery? -- will the chairmen yield to me for a question of mr. gingry? >> yes. >> has it been your experience that a bureaucrat has told a doctor how to practice medicine? >> mr. chairman, there is no doubt that is that -- that has been done by forcing the doctors to accept medicare, accept assignment or -- >> york embarrassment -- reimbursement goes to practice of medicine. we have a government run health care called medicare. does medicare tell doctors how to practice medicine?
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>> absolutely. medicare can deny coverage. >> the gentleman's time has expired. let's proceed to the vote. all those in favor of the kingery amendment say i. all those opposed say no. the notes have it. >> we continue our look at a charge 3200, which is the house of representatives -- at hr3200. it will be subject to a lot of debate this fall when the house returns. we are joined by martin varon of news wires. we have talked about some of the doctor/patient relationship and the politics a little bit of this bill. but i also wanted is that the
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change will be made. anti- locy has made it clear she is comfortable with the higher level. >> what is the relationship between speaker nancy pelosi and the three chairman committees, george miller of education and labor, henry waxman of energy and commerce, and charlie rangel of ways and means it? >> she has had her hands full bringing these three chairmaen, who for obvious reasons come from different backgrounds, constituencies themselves, different jurisdictional interests. and randall for the tax committee obviously has his own ideas about how to raise money for things. and it would be different from the ideas of chairman miller of
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the education and labor committee. from the get go on this, a locy -- nancy pelosi has put a lot of commitment in to bring those three forward and moving them forward in lockstep on this. she did not want to create a situation where the chairman are squabbling on -- among themselves. that has worked out pretty well without too many problems. that is the house of representatives with the way that the house rules are structured. the majority party has a bit easier road to get things through. >> all three committees have passed the exact same version of age -- of hr3200, is that correct? >> nou, there are differences in these bills that will have to be resolved. that is the bulk of the work coming back from recess, for the committees to sit down and get together and resolve those.
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>> what are the significant the vatican -- differences? -- the significant differences? >> let me think about this. one difference is in the energy and commerce committee, chairman waxman had to, in order to bring some of the blue dog democrats on board, the moderate democrats, he had to make some concessions. that resulted in a bill that looks different than what came out of ways and means. the waxman bill exempts more small businesses from the employer-mandate requirement. it also has a bit of a different spin on the public option. it is based on doctors and hospitals being reimbursed on a negotiated rate that the secretary of health and negotiate. and the ways and means bill, for instance, it is pegged to medicare rates. the energy and commerce bill is a bit more favorable to the
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doctors and hospital providers. those are two examples of things that ought to be reconciled. >> we talked a bit about the surtax on high incomes. the energy and commerce had that debate earlier this summer. >> before i begin, let me recognize the distinguished chairman of the ways and means committee, mr. rangel, who is in the room, since this amendment relates -- relates to his committee. it is good that he would be in attendance when i discuss it. mr. chairman, under the pending bill, there is a tax on american citizens depending on their income status. if this bill goes into effect there would be an immediate tax -- surtax on incomes of citizens who made between $350,000 out
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and $500,000 per year. or be a 1% tax. port citizens who make between $500,000 and $1 million there would be a 0.5% tax. and for citizens who make over $1 million, there would be a 0.5 0.4% surtax. those would double in the year 2013 if there is a steady by the omb determines that certain savings have not occurred. what the barton amendment does is direct the study to find that regardless of the savings, that the tax increases on the lower two income brackets do not go into effect. the effect of the barton amendment if adopted would be, beginning in 2013, only those
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citizens who make over $1 million would have their taxes increased by the surtax. the reason that we do not just repeal the tax increase -- and that is why i am glad the chairman of the ways and means committee is here -- is because we do not have the jurisdiction to repeal the tax increase. but we do have jurisdiction over study. so, we use the study as a hook to savy, those citizens who make less than $1 million, to try to save them money until 2013. this is the $1 million taxpayer protection amendment, those that make less than $1 million. >i yield to mr. waldron. >> i have to speak on this in support of it. if you look at the chart up here, my home state of oregon would have the second highest
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income tax rate in the world. we already have the second -- i think highest marginal tax rate in the u.s. of any state. which is a great benefit for mr. and sleaze state because we are having to build a whole new bridge so that -- for mr. tensleensley's state, because we having to build a new bridge to the people can move to washington -- two or injured -- two or yen. i will be supporting the domenick amendment. -- i will be supporting the gentleman's amendment. >> i yield back i am not sure -- i yield back. >> i am not sure how mr. darden is trying to create jurisdiction over this issue -- mr. boorstin
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is trying to create jurisdiction over this issue. but the basic problem i see is that he is doing some kind of gimmick to undercut the revenue committee, and is sort of interesting that the chairman, mr. rangel, is here. the reason i oppose this amendment is that from the very beginning of this debate when president obama talked about the need for health care reform, he pointed out that a good part of the cost, the paygo, if you will, was going to be from cuts and -- in existing programs, medicare in particular. but at the same time, there was going to be a new revenue need. the reason there was going to be a need for new revenue is that in order to cover more people and provide assistance to middle income families through a subsidy, at least up front in the beginning, a certain amount of money was going to have to be available down road as --
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available. down the road, as more and more health care kids income on we save money. -- more health care kicks in, we save money. part of it would be paid for through program cuts and part of it through new revenue. i think that we would be kidding ourselves if we did not realize or acknowledge that some revenue sources is needed. if you look at a revenue source, i think that what the mint -- the ways and means committee came up with is probably the most responsible way of doing this that i can imagine. if you look at this surcharge, it only applies to the top 1.2% of all households in the united states. it would have no affect on 98.8% of all households in the u.s. those are families making between $350,000 and $1 million. they would contribute less than 1% of annual income in order to
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provide access to affordable help care for all americans. i do not think that as much of a contribution when you are going to cover all of these people who have no insurance, plus a number of people who would get a subsidy to help make their insurance affordable to them. we are a community. everyone should help to a certain extent. i think this is the least offensive way of doing it. i know it is not before our committee and maybe we should not even be talking about it today. but of all the proposals out there, this is the least offensive. if you think we're going to be able to do this without some new source of income, you're kidding yourself. i do not represent a poor district. i have a lot of people who would be impacted by this, but i still think it is important to recognize that this is a good way of doing it and something has to be done. this is not all going to be paid for through program cuts. i yield to the gentleman. >> i want to point out one thing. american citizens, taxes are going to go down as a result of
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this bill. [laughter] that may explainç why. because right now, your state are paying too much for health care because there is no containment. >> of the republicans are acting like british parliamentarians. [laughter] ration your mirth. >> as long as they do not act like south korean won's, i will be fine. [laughter] the cost to citizens will go down because it will not have inflated health care costs built in. the amount of uninsured that are walking into emergency rooms are going to go down, so more efficient care will be provided. the amount for cities like mine and states that have shares of medicaid are going to go down. overall, tax expenditures are going to go down, down, down and osorno on tax expenditures. the way everyone should look at this effort is that while -- is that will the overall cost of life be reduced or go up? health care will double in the next five years.
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if we do not fix that, everything we have is going to go up in cost. the question is not, what part of it is going to go up. everything is good to go up a little, but everything is going to go down appreciably a lot. i welcome the study that says what the conclusion of the study will be. the fact is that health care costs are driving everything in this country to be too expensive. when you are buying a car, you're paying a tax. when you buy food, you are paying a tax. when you go to the office, you are paying a tax. we say, no, that is not a good policy and we are trying to take -- to change it. >> will the gentleman yield? >> i do not control the time, but bring it on. >> i thank the gentleman for yielding. >> the difference time has expired. -- the gentleman's time has expired. maybe you could go to mr. blanton.
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>> i would like to make a couple of comments. one is that there is no study that i am aware of that indicates that there is anything that saves money or bends the cost curve. we heard the cbo testify with conclusively -- conclusively that the cost is not go down. the gentleman's guarantee that this is to contain cost is not supported by any information that i am aware of. the tax that we are talking about is a tax that absolutely false on most of the small businesses in america and that gets beyond the $200,000, $300,000 level and their tax would be impacted by this dramatically. the former chairman's amendment, the ranking members amendment, simply if it is going to be this tax, it tries to move it in an area where it does not impact job-creating aspects of small businesses that do have income that might have saved $250,000
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or $300,000. we had a meeting with a number of people this week about the 8% surcharge if you did not provide insurance. all of these saudis as job costing measures at a time when they would like to be -- all of them saw these as job kostis measure-- job costing measures a time when they would like to be hiring. >> if this surtax, particularly on those making less than $1 million per year, many of whom -- maybe one-third -- are small businessmen and women, if it is found by a steady in 2012 that more than enough taxes have been raised for paying for this health care reform act, then we should not continue to tax these individuals. the speaker was asked the same
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question on a sunday morning talk show about a week ago and her response, mr. chairman, was, you know, we would use that excess money to pay down the deficit. goodness gracious, it would seem to me that we would leave that money in the pockets of the small-business men and women so they could continue to create jobs and we have more and more revenue coming in. >> will the gentleman yield? >> it is my time. >> you have got these same people, the democratic majority are going to go after these same people to pay for other things. you better save some for later. >> i yield to the gentleman from florida. >> i thank my colleague. mr. wiener says we're going to lower health-care costs with this bill. this is a study by the joint economic committee, senator brown back is the ranking member.
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it is bipartisan. we should probably look at this graph. it is a small grass,ç but it shows that under this health care bill, health care costs are going up almost exponentially. you are welcome to get a copy, mr. wiener. i do not think there is any evidence to support your idea that this bill will bring down health-care costs. in fact, is going to increase it dramatically. when you look at what the president said, that he would not support any health care bill that did not bring health care costs down, i do not know how he could support this bill based on what the joint economic committee has published in this very thorough analysis showing health care costs going up. >> i yield to the gentleman from louisiana and if there is time, the gentleman from illinois. >> if anyone suggests that if this bill passes that taxes will go down, i suggest they go and read the bill. if you look at this section right here, 4-1, there is a tax
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on anything that is unacceptable. they can actually impose a 2.5% tax on your income. it is so large that the congressional budget office sat here in this room -- unfortunately, it was not a meeting that was open to the public, but i was there. the congressional budget office said that one section alone is going to add $29 billion in new taxes onto the backs of people who are uninsured today. most of those people are making a board of $50,000 per year. it is not just some radical blog that is going to tell you that your gwenn to pay more taxes. the congressional budget office is saying that it will be so. >> i yield to the gentleman from illinois. >> cbo said that obama is cost
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savings are an illusion. -- obama's cost savings are an illusion. >> the gentleman's time has expired. the chair recognizes himself for the last five minutes of debate on this amendment. this is a very confusion -- confusing amendment. this should not even be in this committee, but we checked with the parliamentarians and he said it was crafted in a way that allowed it to be germane. i do not know if that is why the chairman of the ways and means committee is here or not, but this is strange. the bill says that if we do not achieve the savings that we need to achieve, then we would look to revenues. this amendment says that if we do a study, we are going to determine that if the savings --
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if we do achieve the savings, then we will reduce the revenues. the whole bill that we have is paid for out of programmatic savings, cuts in medicare, medicaid -- and if that is not enough, new revenues. this amendment would reduce the revenues. if we make a reduction in the revenue side, then we have to look to see whether we are going to get the savings. if we do not get the savings, this amendment could cost us several hundred billion dollars, if it worked. and there is a lot of comedic -- confusion on whether it works. i think this is a message amendment and i do not even understand the message. but the impact of this amendment would be very destructive to the bill that we have before us. and if the study showed that we did not achieve the savings, we
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would then make a decision -- or really get this decision -- as to how much money -- or redelegate this decision as to how much money would be possible. i urge members to oppose this amendment. it is what we call "gimmicky." it says it is doing something. it says your omb would fight at least $500 billion in savings that would be generated -- would find at least $500 billion in savings that would be generated. and if we did, we would change the surtax of individuals making less than $1 million to never face attack. i do not know what the provisions will be when we get to the house floor. -- less than $1 million to face a tax. i do not know what the provision
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will be we get to the house çfloor. >> will the gentleman yield? >> i will and a second. if it turns out that the revenues are inaccurate, we have to reduce revenues even more. who is asking me to yield? >> the majority committee provided numbers with a description of what this bill does for the district, including talking about the surtax. i would suggest that your side do the same thing. for example, -- and i have a bunch of them here -- it tells the number of small businesses that would receive tax credits. every one of these that item holding is about $12,000 plus, small businesses that help. how many seniors would avoid the doughnut hole in medicare part c? that is thousands. how many families would escape bankruptcy? that is in the hundreds. how many people in the district would get covered?
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in all cases it is over 100,000. and every single case, 99% plus people in the district will not pay the surcharge. we're talking about a tiny number compared to the hundreds of thousands of people that will help because finally they will get insurance. you ought to look at this description so you can take a good look at how your district will be helped by this bill. >> i would just say that under this amendment, after you get some analysis, the first priority will be to reduce taxes rather than make sure we keep those promises. and if we cannot keep those promises, we have to look at further reductions in medicare and medicaid. this is going to cost us hundreds of billions of dollars and not make the plan work. i suppose that is the goal. >> i just want to point out one tax that the minority side refuses to point out.
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we have $2.2 trillion for health care. that is going to go up unless we do something to $3 trillion by 2012. i said to my colleague from louisiana, yes, you can find charges in this bill, but you have to balance it against the close to $3 trillion in taxes for all americans. >> we have completed the debate time. we will now proceed to vote. mr. barton informs me he would like a roll-call vote. >> martin vaughn, that was a little bit about the surtax in the house bill. the senate does not have a surtax, correct? >> correct. the senate has chosen a different option to fund its plan. the details are still up in the air because the finance
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committee senators are still trying to negotiate this and they have not released their legislation publicly yet. the way that is going is that they are talking about a tax on insurance companies, which would affect only what is called " gold-plated plans" or the most expensive plans. those plans that are above $24,000 in annual coverage. it would place a surtax on those with a couple of goals. it would generate revenue in the same way that the house what the surtax does, but also, it would havhelp control costs by steering people away from those very expensive plans and making them more thoughtful about their choices and economizing more. >> back to hr3200.
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employer-provided insurance and individual-purchased insurance, what are the provisions in the house bill with regard to individual-purchased insurance? >> there is a mandate in the bill that is integral to how this works. that is, the house bill would require that every person be covered. you know, that every american purchase a health insurance either through dara employer or through this exchange -- either through their employer or through this exchange. the penalty would be 2.5% penalty assessed on your tax return if you do not have coverage. on your employer side, they want to keep employers providing coverage for people. çthey want to prevent a situatn
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where with the new public plan, new options available through the exchange, the people who now have coverage through their employer migrate to those new alternatives. there's also a penalty in there for employers that do not provide, do not offer affordable coverage to their employees. >> and that penalty is 8%. >> correct, it starts out at 2% for smaller firms and it rises to 8% for the largest firms. >> and that is 8% of payroll. every dollar that you spent to pay employees, if you do not provide coverage, you could be taxed up to 8 cents on the dollar. >> my impression, though, is that large employers spend more on health care than just a% of health -- of a health care -- of payroll. what about just dropping
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insurance and paying the 8%? >> you are right, the typical employer spends more than that on health care benefits. the@@@@+@ @ employee relationship. the idea is that just because there is this new exchange, employers are not just going to suddenly drop that.
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they want employees to feel taking care of. in addition, there is a tax subsidy that is associated with employer-provided health insurance and that does not go away under this bill. if the employer can provide health insurance, there is a building in subsidy that the government is chipping in -- there is a built in subsidy that the government is checking into the worker. that has to be taken into account. >> could you once again, before we show a little bit more ways and means committee debate on health care reform, explain what the exchanges are? >> sherkure, this is a central feature of this new plan and it is meant to help people that do not have insurance through their employer -- in other words, they are in an individual market or the work for small business and are in a small group market -- have more ways to get insurance. currently, in many states there are not a lot of options for these people on the individual
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market and is very expensive. what the bill would create is a national exchange that is regulated, run by a commissioner appointed by the federal government and it would include both private health-care plans and also could include non- profit plants and under the houe bill as it is written now, would also include the government plan. >> is there a penalty for individuals who do not have employer-sponsored health care or do not purchase health care in the exchange? >> there is. >> what is it? >> the penalty is, a person would vote to point represents nine of their income -- would of 2.5-- would 0we 2.5% of their
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income on their tax return. the idea is to get healthier, younger people buying insurance, whereas in today's market in my hobby -- might not be so inclined. -- they might not be so inclined. >> here is about 10 minutes of the debate about individuals who do not have insurance. >> #34. >> thank you. mr. berchtold, you have been hanging out with us all day long and you have had one chance to respond to a question. i figured i would for one that you. >> 34. >> this is the amendment that helps make good on president obama's promise not to tax people making less than
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$250,000. looking at the spreadsheets that we do have from jct and cbo, is it not the case that some of the people that have to pay the 2.5% tax will be making less than $250,000? and is it not also the case that the employer payroll tax will be paid on payroll for people making less than $250,000? mr. ryan, you did ask me a couple of questions i number of hours ago. >> ok, not since dinner. [laughter] >> you asked about the proposal for the tax on individuals without acceptable health care coverage. it is a tax on the individuals' wages over an agi threshold.
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the threshold in 2009 would be $18,700, on a joint return -- 18,007 of dollars on a joint return, and a little over $9,000 on an individual return. yes, i would have to say there is a surtax on individuals making less than $250,000 in that circumstance. you also asked about the% payroll tax that would be applied to non--- the 8% payroll tax that would be applied to non-electing employers. as mr. elmendorf said this morning when we discussed a similar issue, both the congressional but ought -- congressional budget office and joint committee when we estimate the effects, when we do distribution analysis, we see
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the economics of payroll taxes as generally ultimately falling on the employee. >> wateville, thank you very much. -- wonderful, thank you very much. let me quote from mr. obama during the campaign. "middle-class families will see their taxes cut and no family making less than 2 under $50,000 will see their taxes increase -- making less than $250,000 will see their taxes increase." this bill violates that promise and we want to help the majority, help the president make good on his promise. pass this amendment and we will make sure that families making less than 2 wondered $50,000 do not see their taxes -- $250,000 do not see their taxes increase. it is just that easy, it is that simple. these taxes increase over 10 years. they're not the major pay force in this bill.
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they are the punitive penalties designed to force people into the mandate. obviously, we have a policy problem with that. but more to the point, this bill violates the kind of change most people thought they were getting when they went to the polls in november. i bet if you ran a poll, most people believe that if they make less than 2 under $50,000 they will not get their taxes -- $250,000 it will not get their taxes increase because the man they voted for told them they would not. we make this bill law, they get their taxes increase. if we get this amendment, that will not happen. it is that simple. >> mr. blumenauer, u.r.l. -- you are recognized in order to respond. >> thank you, mr. chairman. would that work "that simple." my good friend, mr. ryan, and i occasionally have a chance to
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reminisce about the good old days when he was in charge and he was involved with taxes, deficits, where we had medicare part "d" airdropped in without any expectation of how we were going to pay for it, just a new entitlement. some of us voted against things of that nature. this is structured differently. the first, his proposal would call for a significant increase in the deficit. he is not talking about adjusting the program. he is just talking about eliminating revenues andriving up the deficit. second, he is sort of blowing a hole in the whole concept of insurance. if we are going to have individuals who do not have a feed, not an increase in their -- who do not have a fee, not an increase, but a fee to make sure
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that they do not answer -- that we do not destroy their insurance, what he's going to have is a person who will not get coverage until they get sick. under this provision cannot opt out, get coverage when you need it -- under this provision, opt out, get coverage when you need it. and suddenly make it impossible to talk the insurance reforms that are critical here. you just have people sit back and wait until they are sick. we already have provisions under this bill to help people avoid additional tax by obtaining health insurance coverage. if they have got problems, we have subsidization. if they are not eligible for subsidized coverage, there is a hardship waiver. but what he is talking about, increasing the deficit, destroying the principle of
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insurance, providing incentives for people just to drop in when they need it and have extensive payouts. then in terms of having an employer fee to make sure that people be a part of the system, he would exempt people the payroll of $250,000 the latest information available, that is 2007, i do not know if it is up or down, but is probably that ballpark. there have been some choppy economic waters. he would exempt 99.1% of american taxpayers from dealing with the payroll tax. i think that is a little bizarre. it is a little expensive. it is not increasing the income
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tax. this is taking away some of the principals, some of the fis and the regulating mechanisms -- some of the fees and regulating mechanisms to make the system work. if you want to cut the coverage, cut the coverage. or to reduce the revenues in one place, pay them somewhere else, but do not destroy the principle of insurance. do not drive of the cost of the deficit. that is what you did when you were in charge. we are trying to avoid that and i think we have done a reasonably good job. i would urge rejection of a misguided amendment that takes us back to the days when you were in charge. >> all of those arguments are fine and good, but they neglect the fact that the biggest promise of the last campaign is being violated with this piece of legislation. i do not want to do a rehash of the prior history, but when we
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were in this committee, when we were in charge, the majority offered a prescription drug bill that cost $1 trillion. so, and paid for, i would say. you could easily fall back the $1 trillion in this bill to pay for this. the point is this, you are violating his pledge. this bill breaks the president promised to the people of this country. it's just that simple. roll-call vote, please. >> martin vaughn, we just heard about penalties that individuals could face. what about subsidies for individuals that may not be able to afford health insurance? >> the bill also includes subsidies for low to moderate income people that are going to be seeking coverage through the exchange. they would cover people of 2400% of the poverty level. -- people up to four under% of the poverty level is on a
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sliding scale, so -- up to 400% of the party level. it is on a sliding scale. >> what are your requirements for employers to provide health insurance in hr3200? >> of 5-employers are required to offer affordable coverage -- employers are required to offer affordablç coverage to their employees and coverage that meet certain criteria. if they do not, they are subject to a certain percentage of surtax on the payroll. >> to the offer options, or just one plan? what does the bill say? what some of these details have yet to be flushed oufleshed oute key is that they are for an affordable plan. what does affordable mean? that might require some fleshing out. but there is not a requirement for more than one, but there is a requirement that they offer
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affordable insurance. >> could offer the public option as the plan? >> if they did that, they would have to pay the penalty. >> the ways and means committee debate on penalties for employers also occurred this summer. we want to show you a little bit about that. it is about 30 minutes in length and then we will come back with martin vaughn. >> thank you, mr. chairman. what i am offering is to strike the employer mandate. mr. chairman, the bill we are debating today contains an 8% payroll tax if they do not offer benefits to their employees, but also, if they do not offer the right kinds oveof health benefi. it is not only those businesses that cannot afford to offer health insurance to their employees, but health care coverage that is offered that is
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insufficient by the federal government. it also taxes those who offer sufficient coverage, but employees decide to enroll someone else. it also taxes businesses the federal government decides are not paying enough of the employee's premium. as the national unemployment rate climbs toward 10%, this is the wrong time to increase taxes on our nation's employers. that is why i am offering an amendment that strikes this ill- conceived employee mandates -- employer mandate. mr. chairman, i would like unanimous consent entered into the record, letters from the u.s. chamber, national federation of independent business, and 31 other organizations who have expressed their desire to see the employer mandate removed from the underlying legislation. the u.s. chamber of commerce has
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stated this employer mandate will not increase health care coverage, but rather, lead to the outsourcing and offshore in of jobs, hiring independent contractors as well as reducing work force and wages. the national retail federation, which represents one in five american workers, has said "employer mandates of any kind amount to a tax on jobs. we can think of few more dangerous steps to take in the middle of our present recession. but the nonpartisan budget office has also weighed in saying, as employers required to pay insurance or a fee is likely to reduce employment. even the white house economic model confirms this is true. it projects that an employer mandate included in the bill will result in 4.7 million americans losing their jobs.
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i cannot think of anything worse this congress could do right now in light of our current economic situation that would be as devastating as taxing businesses out of 4.7 million jobs. i urge my colleagues to join with me and support this amendment that would strike the act on american businesses. >> mr. levitt will respond. >> thank you, and to my friend, mr. johnson, i am very glad you have proposed this amendment. this very much across the lines -- draws the lines between those that want to sustain or maintain the status quo and to those who are determined to change it. we on this committee have been talking about this issue for
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years and as washington has talked, the number of people without insurance have grown. i do not know what more could moveç people than 45 million people to 50 million people without insurance. i do not know what is going to take. but if you go into the issues of people without insurance, look them in the eye, i do not see how you can support this amendment. the status quo is not only untenable, but unconscionable. and for the first time, the president of the united states and a majority in this congress are determined to step up to the plate and no longer daud to this
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issue. we have an employer mandate. we have been sensitive. and we have tried to balance this. we have exempted the smaller businesses with payrolls under $250,000 entirely. and what we have also done is to provide tax credits for businesses so that they can provide affordable, comprehensive coverage. what more do you ask? cbo says there will be 97% coverage. a dramatic increase in the coverage today, and my guess is that if you would replace all of us -- if you were to replace all of us with people who had no
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health insurance, that republicans as well as democrats would vote against this amendment. you talk about offshoring. so many of these jobs could never be sent overseas. you have opposition from the retail establishment. those jobs are going to be of short -- offshored? no, the fact is that so many of the businesses have been providing insurance, but a lot of the companies that are not have failed to do so, relying on those who provide insurance to cover their dependents. there has not been a single plan that i know of from the minority, a single plan that would lift the coverage for people in this coverage anything close to 97%.
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no proposal that would be scored as coming anything close. so, i say to you, if you want to pose this, come up with a plan that reaches 97%. come up with a plan. all of those -- all of us hold a town hall meetings and the hardest thing to do is to listen to a comment from people who have no coverage, who cannot afford coverage, who work hard and there is no health care coverage. there is no health reform without coverage. and let me just finish on this. the president has said, a mandate is that we get costs
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under control. a mandate is that we also cover virtually everybody. that is a double mandate. and this bill attempts to meet both mandates. maybe we can do more, and i think probably over time we will in terms of containment of costs, of rationalizing the delivery system. ok, but one thing that i think is untouchable for the president of the united states, and it should be for us, is covering essentially all americans with health care coverage. and if we leave here without anything less, we will not have done our job. we cannot sit here in this committee that has responsibility, we cannot continue to sit here and essentially sit on our hands.
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i oppose this amendment. >> the clr) recognizes mr. brady of texas. >> thank you, mr. chairman. a quick fact check. quoting the cbo, it leaves 17 million people without health care coverage while we're still waiting to see but the cost is. that is about the population of florida. the second fact check is that republicans have a number of proposals to cover the uninsured in america, but we just did not have 24 hours or less to respond to the rush through congress that this bill is taking. but i think mr. levitt is correct, there is a distinction here on both sides of the aisle. the distinction is between those who understand how jobs are created in america and those who have no clue. having run a small business and an organization working with the small businesses for 18 years and struggling to pay health care myself for our workers, i
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do not think this committee fully understands what is wrong with -- a struggle it is for small businesses to keep workers, especially in tough economic times to keep them with health care. i looked at this from a small business perspective of what this mandate would do and according to the national bureau of economic research, who study the impact of a mandate like this on businesses, they made three key points that i think ought to be of interest to this committee. first, who loses their job with a mandate like this? primarily, women, minority, and high-school dropouts. more than 60% of those at risk of losing their jobs are racial and ethnic minorities. who else? minimum wage workers, those earning within $3 of minimum wage would be next at the greatest risk of losing their jobs. and interestingly enough, those
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currently without health care or seven times more likely to lose their jobs than workers presently injured. -- insured. a bill that is supposed to, that is claiming to cover the uninsured is a seemingly at odds with each other. i think you will see companies drop their coverage congressional budget office says requiring employers to cover employees or pay a fee if they do not is likely to cut jobs. in other research, small businesses are disproportionately affected by this mandate and will account for two-thirds of the job loss. that is the fear that our manufacturing companies and the workers in america reflect as well.
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with the national association manufacturers say is that this scheme will, instead, force a calculated cost-benefit on employers that will cause some to reduce benefits for workers, or just drop coverage altogether. i think this provision will backfire on the economy. it will cost us jobs and ultimately drive people out of the coverage that they have. this is a common-sense amendment that deserves support. at least, if used -- if you care about workers in america. i yield. >> of the 17 million, about half of them are undocumented workers. would you cover them with health insurance? >> can you guarantee to me that they will remain on documented? -- undocumented? >> that they will remain undocumented? >> as you go through your immigration reform, a lot of proposals offer amnesty to them. can you guarantee that they will
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remain undocumented? >> no, i do not think senator mccain and other sensible republicans would raise that issue. but do not throw in the 17 million. half of them are undocumented and we will be glad to talk to you about job loss. this side has been in the lead in terms of creating jobs in this country. >> [laughter] reclaiming my time, mr. chairman. i respect you a great deal, but you have lost 2 million jobs in the last five months. unemployment is higher and the economy is getting worse by the day. the president the other day just said that this stimulus failed. >> he did not say it failed. and your talk"a=uq jobs is the same as when we talk about minimum-wage. is the same old song. and the country wants a new tune.
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>> well, they are certainly getting it. [laughter] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> the chair recognizes mr. blumenauer. >> thank you, mr. chairman, and i think this is an important amendment for us to have on the table. it is clear that this provides advantages for a wide variety of businesses because it levels the playing field. now, everybody will be providing health insurance or they will be contributing to overall. it is going to help avoid the slow unraveling of employer- provided health care in this country. we're on a passed unless we do something like the legislation -- we are on a pass, unless we do something like the legislation before us, where we continue to shrink the pool of employer-provided health care.
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we are watching the numbers decline as the premiums go up. decline as the premiums go up. this is an opportunity ilize and reversed it. this is not a huge burden on employers. we have had testified before us a number of examples where people point out that small business is all ready paying far more than 8% and there is an exemption under the bill for the smaller ones. but i would call people's attention to the information from the chamber of commerce. in the second paragraph they are they say in 2007 the employee benefits totaled about 18.6% of total compensation. health insurance is a significant portion of this, and for virtually all of the
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employers that are providing health insurance, this is higher. with any analysis of the information that we have had presented before us, this is not a burdensome level, this is a bargain for most of the small companies. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] this will level the playing field and we will be protecting the employer provided health insurance. failing that, we will see an accelerating decline, as this becomes more and more unaffordable. >> will the gentleman yield? this is not directly an answer to your comments, but i have heard people referring to 50 million uninsured. i would like to put in the
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kaiser family and about 11 million are available for s- chip, 9 million are not u.s. citizens and others are college students who are leading the uninsured. these are the people that we would like to see helped. when we hear that there are 50 million uninsured, it is important to know what will make up of this number. if we take the precious resources that they give us, we can move forward together. >> i appreciate the gentleman talking about the complexity of the number. the high income people do not have a choice, they have problems in terms of the reforms of the legislation and that will help take care of this.
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the denial for pre-existing conditions and the fact that there are people who are finding it unaffordable even at this level. -- that is why we would want to of the assistance of two $80,000 as a minimal amount. you have seen it in your state the increasing burden on employer-provided insurance. the numbers are going down and the premiums are going up and the future is bleak unless we do something similar to the legislation we have before us. >> thank you, mr. chairman. i want to follow up on a statement -- an observation made by the gentleman from michigan. that somehow of this spring's added discussion that reflects the difference between those of us who defended the status quo
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and want change. that is pretty hyperbolic. i will not touch that. but this amendment does separate those who want to place a priority on getting people back to work and those who do not. that is it. there is a lot of talk around this discussion about the number of uninsured. we all know that the number is fluid and the make up the number can change in any discussion. >> what is the breakdown? >> at the end of the day, we ought to be focused on the 14 million plus people in this country who are unemployed and the families that are reliant on the paychecks that are no longer coming. you can begin to look there and say that you have probably 30 million people that now have no hope of getting through the end of the month. that is where we need to focus first. that is what we should be doing.
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this amendment goes in completely the opposite direction. . as it has been said, this amendment creates a payroll tax on small businesses. in fact, the new tax could be as high as 8% of payroll for an entire company. let's really think about why small businesses, if they do not offer health care, why they do not offer health care. they do not because, frankly, they cannot afford it. 49% of small businesses with three workers to nine workers, that is really small business, only 49% of those offered some kind of health care. rather than reduce the cost for them, what this bill does is says, we are going to raise the cost. we are going to start with small businesses that have a payroll of $250,000.
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somehow, that is going to get us to have a more people insured. in response to the gentleman from oregon that this is the step to take toward preserving the employer-based health -- the employer-based health care system, this does not even begin to preserve the employer base. this goes in the opposite direction. even more, this bill says that, if a small business, if one of the 51% of small businesses with three workers to nine workers does provide insurance, the government in washington can say that that insurance is inadequate. let's look at the facts there. the bill says, in order to be adequate, first off, a small business must cover 72.5% of premium costs. in the case of a family, it must
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be 65% of premium costs. 20% of small businesses cover less than 75%. a third of all businesses cover less than 50% of premium costs. right away, you're going to provide and impose this tax. even more, the bill says that, if your employee decides he or she wants to participate in a government exchange and they like a richer plan elsewhere, even though the employer has decided to provide health insurance and is adequate, that employer would have to provide more money toward providing health insurance. it does not make sense. at the end of the day, if you pay tax to a payroll, it is a direct assault on providing jobs in this country.
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we ought not be doing this. an analysis that was performed by a model developed by the council of economic advisers demonstrated that this employee mandate, this tax on small businesses, would destroy -- could potentially destroy 4.7 million jobs. this is why we need to support mr. johnson's amendment. >> mr. johnson is prepared to close. i have two speakers. if you two would take that into consideration, we can dispose one way or the other. >> in any other given time in 2008, there were 65 million people unemployed, period. >> the reason that we are against this mandate is because
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the mandate will put more americans up to 114 million americans onto the government plan. the government plan that we have today, medicaid and medicare, are broken. they are trillions and trillions of dollars in the red. as long as we are going to send secretary geithner to the chinese to buy our bonds and in the treasury department is going to make money, he is correct. the question is how long will people bonus money and how much can we print before we completely destroy this economy? >> mr. johnson. >> thank you, mr. chairman. i would just like to quote fr,m
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mfib. instituting reforms is where we ought to be going. they don't think we're going there by taxing our businesses. it seems to me that, if you are taxing a business that does not provide insurance, something is wrong with that picture. higher taxes are not the answer to get ourselves out of the problems that we are facing. i yield back. >> the question is on the amendment. the amendment is not successful. the clerk will call the roll. >> martin vaughn, we spent the
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day talking about h.r. 3200. what is the next step this fall? what do you foresee happening first? >> as the house lawmakers come back, they have to integrate their bill into the committees. there will be some negotiating over that. we do expect to see a house floor vote probably within the october timeframe. the leadership will also have to respond to the concerns of their democrats, even back in their districts, from their constituents. there are a good deal positives and a good deal of negatives about the bill. the senate is really where the rubber hits the road. they need to either bring 60 senators on board.
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following senator kennedy's death, that means they need to find at least one republican another way to go is that they could pass a bill with a simple majority with 50 votes through a budgetary parliamentary maneuver that is rarely used. to do that, they will have to shave its back and talk some of the provisions and have a more stripped-down bill than they have today. >> have the committees passed out a bill yet? >> yes. the house committee passed down a bill. it was one of the first committees to do so. that bill has been out there. the finance committee has not passed a bill. they are continuing to negotiate. the house committee bill did not get support from any republicans. the goal of the finance committee has been to do a bipartisan bill with the support of at least two republicans. there is a big question as to
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whether they can accomplish that given some of the comments about the direction the democrats are heading from republicans involved in the negotiations. >> so the health committee and the finance committee, did they look at the same bill? or are they each starting from scratch? >> each pretty much started from scratch. they have their basic goals and objectives. president obama has laid out some of the things that he would like to see. but there would need to be some gearing up as things moving forward. they are not the same bill at all >> tomorrow night, we will be looking at the senate debate at 8:00 p.m. eastern time on c- span. by the way, you can see all of this act you can watch it on line as well as on television. what is the impact of the town halls have had in your view?
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>> i think the impact has been pretty big. there is a lot of questions about how much of the concerns raised and the practices -- and the participation has been from activists and how much has been from legitimate constituents. i have questions about this bill. i think it has been a little bit of both. i think that what the town halls have done is to slow the process and ask more questions about what the effects are for these provisions. they brought to light a real trepidation in the electorate about turning over health care to the government, whether or not you think the bill does this. in other words, giving the government a much larger role in
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what now is a market dominated by private companies. >> if you would like to read a charge 3200, it is available at -- if you like to read h.r. 3200, it is available at c- you have read it. >> it is worth getting into the details of this bill. there's no question. i have been impressed with the degree to which the voters, of people, are involved and are trying to find out what the bill does. it is a real positive sign for our democracy and whether or not you slava through -- you slog through the entire bill, it is a good idea to have the key provisions in mind. >> thank you for giving us a little
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we will continue our review of the health-care debate in congress with highlights from the senate committee hearings and this weekend, we will have a comparison of health care systems around the world with t.r. reid, sunday on q and a. >> the health care hub is a key resource. follow the tweets and latest events. share your thoughts on this with your own citizen video, including video from any town hall meetings. and there is more at /healthcare. >> in a few moments, the couple of other respect is on health care, including the alliance for health reform hosted by house
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democrats for health care for seniors. >> president obama will be speaking to a joint session of congress about health care. next, a forum about what may be ahead in the health-care debate. the alliance for health reform hosted the discussion that is a little bit over an hour and 15 minutes. >> we are going to just begin things by asking each of the panelists a single question and letting them respond, and then we will give you a chance to give your questions. are there any problems or questions that you have? communications director, who did all the heavy lifting of putting this session together, will be delighted to help you. and someone for the foundation is also here who can answer from the west -- answer some of your questions.
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let me give you the briefest and least deserved introductions that i can get away with for our panelists. we will start with gail wilensky, an economist and senior fellow at project hope. she has served as president george h.w. bush's health policy adviser. her current areas of concentration also include military held issues, which she has described as one of the greatest fascinations she has run across, and comparative effectiveness. dallas salisbury, on the fourth need on my left, is the ceo of the employee benefit research institute. if you of not discovered the resources yet, you have been missing out. what else does not know about employer-based coverage, you do not need to know. at the end of the table is ken thorpe, head of the health
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policy department at emory university and a member of the partnership to fight chronic disease, a group of more than 100 organizations of every stripe that is trying to shape a health care system that treats chronic conditions better. now let's get to the questions to start this off. gail, why don't we start with you? i mentioned your connection to medicare, and medicare place big role in the plants that are being developed, for generating savings to offset expansion of coverage costs, to testing new models for payment, a whole range of other things. abbas did these provisions likely to survive -- our most of these provisions likely to survive? how should and fisheries feel about those provisions?
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-- how should and fisheries feel about these provisions? >> i regard to proposals regarding medicare that we have heard thus far in many ways as a metaphor for the challenges that we are facing in health care reform in general. the medicare program has a clear is sustainability issue. there are clinical appropriateness and quality issues, as is true for the rest of health care. in some ways, it is lagging even further behind the rest of health care in terms of moving towards integrated delivery systems and more management of chronic disease. we see the challenge that medicare and health care reform in general face a very clearly in the proposals that have been laid out to raise money. what the administration is looking for in order to finance health-care expansion is quick
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money, because it is clear that we can spend money very quickly in order to expand coverage. massachusetts has made that very clear. the problem is that many of the changes, while ultimately likely to benefit the system, medicare, and produce savings over the long term, might not do so in the short term. i will use two examples to clarify the tension and challenges that the administration and congress faced in trying to come up with the money quickly vs things that are in the long term likely to provide sustainable spending that will not be scored by cbo in the short term but one is producing in appropriate emissions. this is a -- reducing inappropriate admissions.
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one out of a five admissions is to free emissions. -- r eadmissi -- readmissions. he might say what is the problem here? the problem is the way you reduce inappropriate in missions best is to get nurses to follow patients when they are discharged to make sure that the medications have been fulfilled and are being taken and that the doctor's appointments or nurse practitioner appointments that are necessary are in fact scheduled and met all of thes. all of these take money in the short term. it is problematic when you look at hospitals with higher readmission rates. they have a lot of medicare and medicaid patients. since medicare reimburses hospitals at a -6% rate, not
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covering the costs, and medicaid frequently does worse, it means that hospitals that are most likely to have these inappropriate admissions are the least able to be able to finance the kinds of strategies in the short term to fix the problem, those that have a lot of medicare and medicaid. can it be done? absolutely. will it produce savings? it will. the problem is the tension -- you want money now for expansions. most of what we wanted to will take some time. the second thing is nursing home rates. it has been now for some time that medicare is a relic of the generous pay your four nursing -- a relatively generous payer for nursing homes. if you pull out money for medicare, which is a former medicare person, i have th
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sympathy to, you are going to put what has been a pretty fragile area of health care into a real financial distress. nowhere do i see additional money for that. these are the tensions. you need to slow spending. you can do it, but the ways that you get money quickly are not the ways that reduce -- that produce the kinds of changes you need to get quality. it is a dilemma. >> thanks. let me turn to dallas , if i can. many of the plans we see emerging from the democratic side impact employers. alternative taxes that would have to be paid to provide or pay for the coverage for their workers. how do you characterize the position of big employers, or for that matter, a small
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employers, all the reform proposals we have seen so far? >> some things are a sense of deja vu as we started doing surveys on this in 1981. consistently, if you think about employer opinion, the number one issue they have always cited is similar always citedgail just -- i have always said it is similar to what gail just cited, cost. the on sustainability of the existing system, be it public or private, on a cost basis. the second reality that employers deal with across the spectrum, and have a four decades, is the key role that they recognize health insurance pays in attraction, retention, and even in the exit decision. our value benefit surveys that go back to the early 1980's
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repeatedly underline that 80% of workers say that health insurance is the number one most important supplement to pay. if you then say you can add a second benefit, what would you want, 36% say more help insurance. when you ask are you willing to take a reduction in current wages in order to have better health insurance, over 50% consistently say yes. then you take another factor -- about 1/3 say they are in their current job because of the health insurance. if you want to keep people, that is a good thing. you what labor force mobility, some employers do, that is a bad thing. 35% say that health insurance was the key factor, the most important factor, in taking the last of that they talk. -- taking the last job that they took. it is in very important to job
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selection. and players are in a catch for -- employers are in a catch-22. the employer wants choice and flexibility. that comes down to what big business has supported since the early 1970's, when it was enacted in the employer retirement income security act. it allows employers to "self- insure close " to avoid 100% of state law, a state mandate, state differentiation, and maintenance of that has been a number one priority of all businesses since that point in time. in the current debate, if one tries to find a differentiation on that one cannot, because one of the strongest points made in the website and speeches and
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testimony by the small business and, the chairman and national federation of independent business, but they want out of health reform is to have for every small business the equivalent of an aggressive pre- emption without having to self- in short. they want the government to sit here is a high deductible, catastrophic protection program that is the bitterest of bare bones coverage and avoids personal financial disaster, which any small business should be able to provide on a nationally consistent basis through state cross border purchase, etc., with a structure, be it a co-op or association health plan, so that they can avoid 100% of the current state mandate, regulation, etc. the other piece of that flexibility that comes through from all of the groups is most
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readily identified as a total repudiation of tax change of employment-based health benefits, which the largest businesses say maybe a little, but as the months have gone by, that seems to have dropped off in any willingness to discuss that. in the clinton years, and during the 1980's, this was very heavily debated on capitol hill. the tax reform act of 1986 included many, many debates and discussions and the so-called treasury one in 1983 and 1984 would have a fundamentally change the tax treatment of employment-based health benefits. this is not an issue, but the positions have not changed. the most important issue in the context of the house and senate bills, beyond the changes in the house bill that are uniformly opposed by businesses, are
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issues related to mandates, be they individual or employer- mandates across the business spectrum, when one looks or listens, any form of employment pay or play amended at this point is generally uniformly opposed, even though they have been willing to live with some of that in massachusetts. that was the price of the inevitability if you read some of the surveys. on the issue of the individual mandate, some flexibility, but not much. the general statement that this does is make across the board in their trade associations is that any cost savings need to come out of the system in order to pay for the universal coverage, and it should not be done in a way that leads to cost shifting. you'll also find in the positions fairly uniform opposition to the public plan or a government takeover.
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i will close with the final irony. the only business group at this point that has been willing to almost all the business entities and groups have taken the position of plan a, this is the necessity of comprehensive reform because the current system is unsustainable. there is no plan b, and there must be reformed, and if you look at the letters and the statements that they send to capitol hill, one of them is dated june 8. we have problems with any change in taxation of health benefits and wheat favor no employer mandate, and we want national uniformity with the preemption
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related to this, but we still strongly support comprehensive health reform. if you go to the web site, you get something similar. if you go to the business roundtable, this is on their web site. the verbatim text of a conversation in early august. ugust, and it is the same type of thing -- support for most the provisions that risa mentioned, expect when one gets to the specifics. i was born and raised in washington at the feet of great senators, and one's staff produced a book called "the dance of legislation," good for this topic and others. henry jackson said, "paid no attention during the process,
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because legislation is like making sausage, and at the end of the day, you just want a compromise that has a tasting good." that is where we are at here. tremendous disagreement over the details, but a recognition that employees want health care, that employers must make sure they had it. but employers don't like being told to do anything, so they want a free rein it tied to the current pre-emption. that seems to be universal. >> okay, see how easy this is going to be? let me finish off this initial round by turning to ken thorpe. everybody u.s. spoken so far has talked about health care costs. -- everybody who has spoken so far has talked about health care costs. they have been criticized severely for not doing enough to hold down health-care costs. i wonder if you think that is a
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fair criticism. if it is, what changes would you advise congress to make and the president to make in this final plan? keeping in mind what the nfib and the chamber were saying. >> it is a top starting point, but thanks, ed. we started this discussion about health care reform trying to address two major issues. one is to move towards universal coverage. i think it is broad agreement about that as an objective. obviously, there's a disagreement tactically about how to do it. but i think we have a broad agreements about moving to universal coverage. 9% of the attention and discussion and reporting on the issue has focused -- 90% of the attention and discussion and reporting on the issue has focused on the discussion of moving to universal coverage. the other thing we are trying to do, when you look back to the campaign and the candidates
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talking about this, was to control the growth in health care spending. that was a major objective of health care reform. i think that while the reform packages, as they stand, are a good start, none of these things are going to be perfect. the question is, directionally, be it moving in the right direction? i think so. but i think if if we do this in steps, which i think we have to -- this will not be one bill and then we go home and forget about it -- we will pass something, i hope, and then come back and improve on the legislation. but what we have to do is focus more on the coming months and years on finding ways to control the growth in health-care spending in addition to moving to universal coverage. if we are going to be serious about it, we have to go back to the basics about what is driving the growth in spending. gail touched on one of the issues. one is that the share of adults that are clinically obese in this country has doubled since
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1993 that doubling by itself accounts for 1/3 appropriate -- doubled since 1990. the doubling by itself for 1/3 of the growth in health-care spending. the rate of treatment of chronic illness in this country is rising at a very rapid rate across the board. kids, adolescence, and young adults, seniors as well. we have to pay attention to a broader toolkit than we have traditionally used to attack this issue of lifestyle, but to do it in a way that is not punitive, do it in a way that is awful, do it in a way that gives people options about four -- do it in a way that is thoughtful, do it in a way that gives people options on how they work. no. 2 is when you look at how we spend the money, 75% of the spending is on chronic illness. in medicare, 95% of the we spend
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is related to chronically ill patients. the irony is that medicare is probably the only program where we do absolutely no care corp. nation. of any program needing to have care coordination built into it, working with patients at home, making sure they are not admitted to a hospital in the first place, as gail talked about, reducing the rights of free admission, improvements in the program would improve the quality provided to the beneficiaries at the end they would save money. one of the things we could do is provide care coordination overtime nationally in the program by building on this medical model but rebuilding community-based prevention. using nurses and nurse practitioners and care providers to work with patients and keep them healthy, keep them out of a
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hospital, and keep them from being readmitted. we will have to invest in this. this is an important change in the delivery system infrastructure, one well worth making. it will provide dividends over time, no question. i would be a quick financial example. if we are going to build kerik what a nation into the program nationally, -- bill to care coordination into the program nationally, based on things in vermont and some other states that do this with a population, it would cost about $25 billion, $34 billion over the next 10 years. that sounds like a lot of money, and it is. but in the context of the numbers we are talking about in the overall package of reform, those are the second and third decimal points of what we are looking at. but yes, it is going to cost money to do this. if we took readmission rates in
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the program from 20% and cut them in half, which we know we can do -- we have programs in place in pennsylvania and colorado and other states that have been showed through randomized trials can cut readmission rates in half. medicare has high rates. mission. if we build that program into this care coordination model, medicare, we could save $100 billion over the next 10 years on just that one aspect of care coordination. we now do this. we just have to make the investment. -- we know how to do this. we just need to make the investment. if we are really going to deal with the long-term deficit. we have to address per capita growth in medicare spending. if we are going to improve the quality of care in the program, we need to make the investments in primary prevention, but we really need to change the delivery model to improve the quality of care provided,
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improve the health of seniors, and we did a lot to reduce readmission rates in this program. but we cannot do it within the current payment structure and delivery model that we have. as part of the promise of reform, we should not just doing health insurance reform. that is a major piece of what we should be doing, but we should also be giving health reform, which is really trying to find ways to improve the health of the population, redesigning, re- engineering the delivery model to improve the quality of care, and at the end of the day, but the the public and private sector, we have the chance of producing a better health care system that generates better outcomes. >> thank you. let me just say that there are green cards in your pockets to buy questions on. given the array of eager people in front of me, i would urge you to actually ask a question or
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early, because you probably like it has to have your question read -- probably will not get a chance to have your question read, if that is the way you choose it. we have microphones, so raise your hand and please wait for the microphone to reach you so that those of us around the room and around the country can hear you. identify yourself and keep your question as brief as you can. right in front of me is our first questioner. >> i was curious how each of you think the threat of death panels has been addressed in recent weeks. and have any of you at the opportunity to read this book that the veterans are suppose to have the opportunity to receive injured veterans that may actually give them, it seems,
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the option of choosing death over life. it was addressed on fox news and the former bush administration -- it was addressed on fox news on sunday morning a week ago. >> i have not read the va booklet. i will not comment on that. i would like to comment on the death panels' charge, which i have done a number of times. i think is really unfortunate that this has been raised and receive some attention -- received so much attention, because there are serious issues to debate in the health care reform -- how we finance the money, the whole notion of a public plan, whether it is or is not compatible with private insurance, whether we are not talking enough about reforming health care costs and only about health insurance reform. many issues.
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i regard the death penalt -- death panel as a red herring issue. to the extent that we're proposing payment for physicians that are asked by the beneficiaries, the patients, to have counseling on high that the hospice benefit or end of life directives once every five years -- the reason it is unfortunate is twofold. in the first place, the hospice is already a medicare-covered benefit now. in addition, and nursing home administrators and hospital admissions individuals are supposed to ask people who are on medicare when they are admitted to hospitals and nursing homes if they have the advance directives, and if so, to mark it in their cars so that this advance directives can be followed. -- market in the chart so that
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the advanced directives can be followed. i regard this as a way to pay physicians to provide counseling if they are asked to buy their patient. and finally to empower patients -- fundamentally to empower patients to have their wishes known about advance directives if they choose to do that. i do not know how many you have advance directives. i do. when i was at medicare, this is when this was first arose with medicare. to allow people, not when they are -- to allow people to have this discussion with their physician or their nurse practitioner or their family members, to try to help them think through what is an issue that individuals may face, being put in a position when they are not able to register their own will in turn is of how they would like to be treated, is an
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important part of life. it does not require people to have these discussions, just like medicare does not require people to have the hospice as a benefit. it allows it. i think it is a major empowerment for seniors, but any senior that does not want to have this discussion, either about a hospice benefit our advanced directive, may not do so, and that is why i find it so upsetting that there is this notion of death panels. >> i think that you said it beautifully. as a geriatrician, i have to comment, because what people don't often appreciate is that the vast majority of people don't really understand what kind of care is available to them at the end of life. what kind of palliative care they can access that would actually make their quality of life better. our foundation has funded a lot of this research. it is critical that people get this information.
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you said it so well, but i think that for those of us who have that for those of us who have actually had to counsel this is an important part of being able to do what we want to do, which is delivered a high quality care. >> i recently lost my father, just before his 94th birthday, and both of my parents had the advanced directives, i can just note 93.5 and 92 they were happy that medicare was providing for the hospice care that he got at the end of life. this is extremely unfortunate that this has been turned into political rhetoric. this is something that i fully agree with what has been said.
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>> i am right behind you. >> i am wondering if the panel thinks that the public plan option is dead, or if this is not dead, if it would be advisable in order to have health reform legislation for this to go away quietly. away quietly and disappear. >> it clearly is not dead. it is one of the most contentious issues, and unfortunately, it seems to have dug itself into a prized possession -- position that is going to make it hard to negotiate around, because you have people like the speaker of the house and howard dean, in a program that i did with him, indicating that without a public plan, health care reform is not worth doing.
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other people who have set having a public plan is going to impact of the rest of health care and have a lot of negative consequences. as i indicated, i think that a public plan is not desirable as and addition, because i do not believe that a public plan will avoid using the power of government to set below market reimbursement -- that is, to not, in fact, paid for the cost of health care being provided. we see this in medicare. medicare pays physicians 20% less than private plans. medicare pays hospitals about 6% less than their costs. if you have a public plan also doing this, you are going to do what medicare does, which is push costs into the private sector, which will come over time, unravel private insurance.
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there are a lot of ways to accomplish, in my view, what a public plan has been postulated as doing in terms of driving change, making sure that there are choices available, and making sure that insurance companies don't discriminate according to health status and pre-existing divisions. which is a part of any insurance reform that is likely to be a package. but it is very unfortunate, and particularly, in some ways, frustrating, because as several of us have mentioned, many of us -- medicare in many ways is the least desirable model to think about driving to and an integrated delivery system that focuses on chronic disease management and moves away from disease focus an acute care and into one of wellness in managing chronic disease.
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medicare is even a step behind the private health care system, which is typically too little of that as it is. -- which does pitifully too little of that as it is. we have to be clear as to what people look to for a public plan and other strategies to achieve them, which i think are achievable. but when people in leadership positions making statements that without this contentious strategy, health care reform is not worth doing, you put yourself in a box that i think as a politician you never want to be in. >> i want to comment from my experience working on this 15 years ago with president clinton. at that time, we really had a strategy that was universal coverage or bust. and we had l bust.
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my concern with this discussion -- i want to take a step back -- we are trying to accomplish the slowing of health care spending in the public sector and private sector to make it more affordable for families and business to keep health insurance and improve the quality of care that we get. and we want to move to universal coverage. we are having a technical discussion on how to do -- tactical discussion on how to do it. one of the things we should be doing is adding to and building on some of the good pieces that are already in the legislation on cost control, and overtime trying to expand and so that we can do these programs nationally. discussion about the public option speaks volumes to the fact that we need to build in more things that are going to control the growth of health care spending. for me, the best way to do this
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is to attack the core problems -- the explosion of chronic disease, the fact that we have a poorly managed chronic illness in this country. we can do better on both of those fronts. . this is something i felt -- that i think we could build a bipartisan approach to do. the growth in the partnership to fight chronic disease, i have 120 groups in this and we have the national retail federation and the aarp, and we have come together to agree on this issue across the table. this is built on the two principles of primary prevention, and modernizing and improving how we deliver health care. that is the direction that we should be going on this.
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we are doing cost containment. that is the area that we need to focus on, not to derail less of the other objectives as we go to universal coverage. >> i want to add one thing, which came to mind, when he did his opening comments. universal coverage to many people means everybody has health insurance. if one uses the pension exam and apply it to health benefit programs, coverage doesn't mean you have health benefits, it means you have access. participation means you have it. this goes back to the debate in 1991 towards the end of the bush administration. is the public plan, is it using the term of universal coverage as the objective of everybody
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actually having health insurance, everyone as a participant in a program. if one looks at the group's ken just mentioned, the nfib explicitly says their definition of coverage is the old bush administration definition. it is access to the opportunity to purchase coverage, it is not participation. if one looks at other business group physicians it is coverage = access, not coverage = participation. -- coverage equals access not coverage equals participation. they are equating it to participation and arguing the public plan is the way to get participation, and all the other places like massachusetts
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where you do not have universal participation or even the netherlands, where you do not have universal participation, you have 3% choosing not to purchase. i think the public plan issue ends up being this absence of a clear debate over and participation verses access, which underlies a bunch of it. >> that is a completely different issue. you can have a mandate for individuals to have coverage and not have a public plan. it is a question of how you want to enforce it. rather than talking about the public plan as the holy grail, we ought to indicate what it is we are trying to accomplish and
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seeing whether it there are strategies. massachusetts has a soft mandate where they allow people without access to affordable coverage to not be fined. the fine itself is quite gentle. the question on whether you want to push required coverage is a good issue to have in the open for people to be debating and not hiding behind this debate about a public plan. we need to be sure we understand what it is you think it will do for you. >> i believe we have you here first and then we will go there. >> i am from the cleveland [unintelligible] what are the issues you guys think congress and president obama will be able to achieve consensus on?
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what are the issues that will be too controversial that they will get tossed by the roadside? >> i am optimistic on the issue of cost that we can do something meaningful in modernizing the medicare program and do something effective in helping to slow the growth on medicare by improving the quality of care we provide in the program. those are the purchase that are well-understood in the private sector. they are approaches we have seen other states do this. they passed statewide legislation that would modernize the delivery system infrastructure in those states. it had wide bipartisan support, so those are areas where we can build bipartisan support on.
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they are common sense things to do. there are things we have been talking about for the last year as central to doing health reform. the road to universal coverage always has been bumpy. i think we can make steps to get there. the question will be much do we chew off this time? whatever we pass is not going to be perfect. if we can pass something that is fairly major with the notion we have made in the right direction, that we can take another whack at it next year is the way to go. it will be difficult to get it passed in one fell swoop. we learned that 15 years ago when we had a comprehensive package. perhaps if we had broken it up and had a trajectory of two years but an agreement on where
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we will end up, then maybe we can get it done. >> i don't read the answer to your question. it is a very good one. it will depend on how much can be financed. as a result of the tarp package and this stimulus bill, there is no additional appetite in the congress to have any additional unfunded expenditures which has made all of this more difficult. the question is going to beat where will there be agreement on funding, not just among congress by acknowledged by the congressional budget office as being real money in the relevant time range. i don't know how much agreement will be possible in terms of what that package looks like.
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it may well be smaller than what we are talking about right now, $900 billion over 10 years. my assumption is that the subsidies at the higher end of the income scale will be cut back or possible eliminated so that more concentration will be on expanding medicaid coverage, and subsidies beyond that to purchase health care in a health purchase health care in a health insurance exchange, but how big and i do not know whether or not this will be a strategy where we go along, as people talk about how this is only democrats and down to the reconciliation process, which would be unfortunate, but has clearly been raised as a


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